Basic Information
| Provider Information | |||||||||
| NPI: | 1932772340 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | YVONNE NICKERSON LICSW LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1192 | ||||||||
| Address2: | |||||||||
| City: | MASHPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026491192 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085248511 | ||||||||
| FaxNumber: | 5084331871 | ||||||||
| Practice Location | |||||||||
| Address1: | 11 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | MASHPEE | ||||||||
| State: | MA | ||||||||
| PostalCode: | 026497134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5085248511 | ||||||||
| FaxNumber: | 5084331871 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/22/2021 | ||||||||
| LastUpdateDate: | 07/22/2021 | ||||||||
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| AuthorizedOfficialLastName: | NICKERSON | ||||||||
| AuthorizedOfficialFirstName: | YVONNE | ||||||||
| AuthorizedOfficialMiddleName: | CF | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5085248511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LICSW | ||||||||
| NPICertificationDate: | 07/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.