Basic Information
| Provider Information | |||||||||
| NPI: | 1881220051 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | TERESA | ||||||||
| MiddleName: | L DOMINIQUE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | LLMSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WILLIAMS | ||||||||
| OtherFirstName: | TERESA | ||||||||
| OtherMiddleName: | L DOMINIQUE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 500 HANCOCK ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486024224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897973400 | ||||||||
| FaxNumber: | 9897990206 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 HANCOCK ST | ||||||||
| Address2: | |||||||||
| City: | SAGINAW | ||||||||
| State: | MI | ||||||||
| PostalCode: | 486024224 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897973400 | ||||||||
| FaxNumber: | 9897990206 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2020 | ||||||||
| LastUpdateDate: | 03/19/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 03/19/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | 6801106528 | MI | Y | Behavioral Health & Social Service Providers | Social Worker |
No ID Information.