MEDICARE: ELIZABETH DAWN NICKELS 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	COO4526	NC

General Provider Information

NPI Number	:	1689717910
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH DAWN NICKELS LCSW

Provider Business Mailing Address
First Line	:	5862 N HILLS DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-4271
Country	:	US
Telephone Number	:	919-786-9916
Fax Number	:

Provider Business Practice Location Address
First Line	:	5862 N HILLS DR
Second Line	:
City	:	RALEIGH
State	:	NC
Zip	:	27609-4271
Country	:	US
Telephone Number	:	919-786-9916
Fax Number	:

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

Provider Enumeration Date	:	02/15/2007
Last Update Date	:	07/08/2007

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