Provider Demographics
NPI:1063166684
Name:NETHERY, NICOLE RENEA (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEA
Last Name:NETHERY
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6691 W LEGACY LN
Mailing Address - Street 2:
Mailing Address - City:ELLETTSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47429-9267
Mailing Address - Country:US
Mailing Address - Phone:812-272-0591
Mailing Address - Fax:
Practice Address - Street 1:6691 W LEGACY LN
Practice Address - Street 2:
Practice Address - City:ELLETTSVILLE
Practice Address - State:IN
Practice Address - Zip Code:47429-9267
Practice Address - Country:US
Practice Address - Phone:812-272-0591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34008563A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical