MEDICARE: LIBERTY LOUISE NICHOLAS 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	55861	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	99-4129751	OTHER	TX	PRIVATE THERAPY PRACTICE

General Provider Information

NPI Number	:	1861254575
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIBERTY LOUISE NICHOLAS LCSW

Provider Business Mailing Address
First Line	:	15514 RIVER BND
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78247-2919
Country	:	US
Telephone Number	:	512-596-5805
Fax Number	:

Provider Business Practice Location Address
First Line	:	15514 RIVER BND
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78247-2919
Country	:	US
Telephone Number	:	210-685-0711
Fax Number	:

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

Provider Enumeration Date	:	01/29/2024
Last Update Date	:	08/16/2024

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Directions to “ LIBERTY LOUISE NICHOLAS LCSW” Practice Location

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