Basic Information
| Provider Information | |||||||||
| NPI: | 1619142767 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICKELSON | ||||||||
| FirstName: | AUTUMN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1222 10TH STREET, SUITE 211 | ||||||||
| Address2: | NORTHWEST CENTER FOR BEHAVIORAL HEALTH | ||||||||
| City: | WOODWARD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805713231 | ||||||||
| FaxNumber: | 5805718609 | ||||||||
| Practice Location | |||||||||
| Address1: | 1222 10TH STREET, SUITE 211 | ||||||||
| Address2: | NORTHWEST CENTER FOR BEHAVIORAL HEALTH | ||||||||
| City: | WOODWARD | ||||||||
| State: | OK | ||||||||
| PostalCode: | 73801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5805713231 | ||||||||
| FaxNumber: | 5805718609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/29/2008 | ||||||||
| LastUpdateDate: | 11/30/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 3847 | OK | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 200407870 | 05 | OK | MEDICAID |