Basic Information
| Provider Information | |||||||||
| NPI: | 1619081486 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKELSON | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.S.W., L.C.S.W. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 101 CABARRUS AVE E STE 200 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280253781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888497379 | ||||||||
| FaxNumber: | 8558577333 | ||||||||
| Practice Location | |||||||||
| Address1: | 101 CABARRUS AVE E STE 200 | ||||||||
| Address2: | |||||||||
| City: | CONCORD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280253781 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8888497379 | ||||||||
| FaxNumber: | 8558577333 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/18/2006 | ||||||||
| LastUpdateDate: | 08/06/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C001740 | NC | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
ID Information
| ID | Type | State | Issuer | Description | 6003647 | 05 | NC | MEDICAID | 146CW | 01 | NC | BCBS | OTHER | 477039 | 01 | NC | HUMANA GOLD CHOICE | OTHER |