Provider Demographics
NPI:1366528788
Name:NICHOLS, ALTON J III (LICSW)
Entity type:Individual
Prefix:
First Name:ALTON
Middle Name:J
Last Name:NICHOLS
Suffix:III
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:152 NORTH ST
Mailing Address - Street 2:SUITE 330
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-5149
Mailing Address - Country:US
Mailing Address - Phone:413-443-8480
Mailing Address - Fax:413-443-8455
Practice Address - Street 1:152 NORTH ST
Practice Address - Street 2:SUITE 330
Practice Address - City:PITTSFIELD
Practice Address - State:MA
Practice Address - Zip Code:01201-5149
Practice Address - Country:US
Practice Address - Phone:413-443-8480
Practice Address - Fax:413-443-8455
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10288641041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP20795Medicare ID - Type Unspecified
MAS52238Medicare UPIN