MEDICARE: MRS. SHERILEE CHAVIS NICHOLSON LCSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	1844C	AL
2	1041C0700X	Clinical Social Worker	CSW003780	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	2021808556	OTHER	GA	MEDICARE

General Provider Information

NPI Number	:	1689646432
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SHERILEE CHAVIS NICHOLSON LCSW

Provider Business Mailing Address
First Line	:	50 MEADOW VALLEY CT
Second Line	:
City	:	MIDLAND
State	:	GA
Zip	:	31820-4393
Country	:	US
Telephone Number	:	251-533-9875
Fax Number	:

Provider Business Practice Location Address
First Line	:	50 MEADOW VALLEY CT
Second Line	:
City	:	MIDLAND
State	:	GA
Zip	:	31820-4393
Country	:	US
Telephone Number	:	251-533-9875
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/06/2006
Last Update Date	:	10/08/2012

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