Provider Demographics
NPI:1720801376
Name:NICHOLAS, DESARIE (LCSW)
Entity type:Individual
Prefix:MRS
First Name:DESARIE
Middle Name:
Last Name:NICHOLAS
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 1:2410 HAVILAND AVE S
Mailing Address - Street 2:
Mailing Address - City:LEHIGH ACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33973-3779
Mailing Address - Country:US
Mailing Address - Phone:347-469-5308
Mailing Address - Fax:
Practice Address - Street 1:200 S SERVICE RD STE 108
Practice Address - Street 2:
Practice Address - City:ROSLYN HEIGHTS
Practice Address - State:NY
Practice Address - Zip Code:11577-2133
Practice Address - Country:US
Practice Address - Phone:516-212-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY098452-011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical