Provider Demographics
NPI:1558180109
Name:NICHOLSON, KIMBERLY SHANETTA (LCSW-A)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SHANETTA
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LCSW-A
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:NICHOLSON
Other - Last Name:PEARCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1503 WAYNE MEMORIAL DR STE E
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-2203
Mailing Address - Country:US
Mailing Address - Phone:919-587-0001
Mailing Address - Fax:919-587-0007
Practice Address - Street 1:1503 WAYNE MEMORIAL DR STE E
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-2203
Practice Address - Country:US
Practice Address - Phone:919-587-0001
Practice Address - Fax:919-587-0007
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0201061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical