Basic Information
| Provider Information | |||||||||
| NPI: | 1124452008 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | MSW, LMSW, CSWA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 312 E 3RD ST | ||||||||
| Address2: | |||||||||
| City: | THE DALLES | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970582204 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412965452 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 965 TUCKER RD | ||||||||
| Address2: | |||||||||
| City: | HOOD RIVER | ||||||||
| State: | OR | ||||||||
| PostalCode: | 970319591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413866665 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/27/2013 | ||||||||
| LastUpdateDate: | 04/27/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/17/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.