Basic Information
| Provider Information | |||||||||
| NPI: | 1518350222 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLAS | ||||||||
| FirstName: | ETHAN | ||||||||
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| Credential: | LCSW, LAC, LMSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5593 HIGHWAY 311 | ||||||||
| Address2: | |||||||||
| City: | HOUMA | ||||||||
| State: | LA | ||||||||
| PostalCode: | 703602866 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9858682620 | ||||||||
| FaxNumber: | 9858688547 | ||||||||
| Practice Location | |||||||||
| Address1: | 1585 3RD ST | ||||||||
| Address2: | |||||||||
| City: | FORT POLK | ||||||||
| State: | LA | ||||||||
| PostalCode: | 714595102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3375313942 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2015 | ||||||||
| LastUpdateDate: | 06/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 1548 | LA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 104100000X | 12901 | LA | N | Behavioral Health & Social Service Providers | Social Worker | 1041C0700X | 12901 | LA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.