Provider Demographics
NPI:1992734339
Name:NICHOLSON, ELLEN ELLIS (MSW LICSW 106577)
Entity type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:ELLIS
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MSW LICSW 106577
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TER HEUN DR
Mailing Address - Street 2:
Mailing Address - City:FALMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02540-2525
Mailing Address - Country:US
Mailing Address - Phone:508-540-6550
Mailing Address - Fax:508-540-7480
Practice Address - Street 1:200 TER HEUN DR
Practice Address - Street 2:
Practice Address - City:FALMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02540-2525
Practice Address - Country:US
Practice Address - Phone:508-540-6550
Practice Address - Fax:508-540-7480
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2009-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1065771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P04165Medicare ID - Type Unspecified