Basic Information
| Provider Information | |||||||||
| NPI: | 1811965270 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICCUM | ||||||||
| FirstName: | CHERYL | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2703 REDRIVER CREEK DR | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782593541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109165371 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3851 ROGER BROOKE DRIVE | ||||||||
| Address2: | BROOKE ARMY MEDICAL CENTER | ||||||||
| City: | FORT SAN HOUSTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 78234 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2109165371 | ||||||||
| FaxNumber: | 2109161602 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | R039435-1 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.