Provider Demographics
NPI:1063608479
Name:NICOL, KATHLEEN (LICSW)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
Last Name:NICOL
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:UNIT 33100 BOX LANDSTUHL
Mailing Address - Street 2:
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09180-3100
Mailing Address - Country:US
Mailing Address - Phone:314-590-4058
Mailing Address - Fax:
Practice Address - Street 1:UNIT 33100 BOX LANDSTUHL
Practice Address - Street 2:
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09180-3100
Practice Address - Country:US
Practice Address - Phone:314-590-4058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-19
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC50078443101Y00000X, 101YM0800X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101Y00000XBehavioral Health & Social Service ProvidersCounselor