1477684801 NPI number — MR. PATRICK FRANCIS NICHOLS LCSW CSAC

Table of content: MR. PATRICK FRANCIS NICHOLS LCSW CSAC (NPI 1477684801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477684801 NPI number — MR. PATRICK FRANCIS NICHOLS LCSW CSAC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NICHOLS
Provider First Name:
PATRICK
Provider Middle Name:
FRANCIS
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
LCSW CSAC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1477684801
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/09/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2241 RYAN DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DODGEVILLE
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53533-9274
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
608-827-7220
Provider Business Mailing Address Fax Number:
608-827-7223

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6502 GRAND TETON PLZ
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MADISON
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53719-1047
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
608-827-7220
Provider Business Practice Location Address Fax Number:
608-827-7223
Provider Enumeration Date:
03/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  4082-123 , registered in the state of WI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 13683 . This is a "ADDICTION COUNSELOR" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 4082-123 . This is a "LICENSED SW" identifier , issued by the state of ( WI ) . This identifiers is of the category "OTHER".
  • Identifier: 39644000 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".




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