Provider Demographics
NPI:1306293907
Name:NICHOLSON, LAQUESHA KAMEIL (LCSW)
Entity type:Individual
Prefix:
First Name:LAQUESHA
Middle Name:KAMEIL
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:KAMEIL
Other - Middle Name:LEE
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:PO BOX 16353
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19114-0453
Mailing Address - Country:US
Mailing Address - Phone:267-344-8384
Mailing Address - Fax:
Practice Address - Street 1:2117 RAVENWOOD RD
Practice Address - Street 2:
Practice Address - City:FOLCROFT
Practice Address - State:PA
Practice Address - Zip Code:19032-1510
Practice Address - Country:US
Practice Address - Phone:267-344-8384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-24
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HILCSW45491041C0700X
PACW0211011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical