MEDICARE: MRS. CLAUDIA SORRELLS NICHOLS 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	SW7294	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SW7294	OTHER	FL	LICENSE PRACTICE NUMBER

General Provider Information

NPI Number	:	1790780906
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CLAUDIA SORRELLS NICHOLS LCSW

Provider Business Mailing Address
First Line	:	5950 WOLFGANG DR
Second Line	:
City	:	MILTON
State	:	FL
Zip	:	32570-8750
Country	:	US
Telephone Number	:	334-447-9623
Fax Number	:

Provider Business Practice Location Address
First Line	:	5950 WOLFGANG DR
Second Line	:
City	:	MILTON
State	:	FL
Zip	:	32570-8750
Country	:	US
Telephone Number	:	334-447-9623
Fax Number	:

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

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	12/20/2011

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