Provider Demographics
NPI:1427312834
Name:NICKEL, MARISSA (LCSW)
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:NICKEL
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 1:3903 W GREENBRIER DR
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-4522
Mailing Address - Country:US
Mailing Address - Phone:208-371-5733
Mailing Address - Fax:
Practice Address - Street 1:410 S ORCHARD ST
Practice Address - Street 2:STE. 232
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1260
Practice Address - Country:US
Practice Address - Phone:208-371-5733
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2016-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLMSW-29805104100000X
IDLCSW-332271041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker