Provider Demographics
NPI:1902266612
Name:NICKELBERRY, DONNA JEAN (LICSW)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:JEAN
Last Name:NICKELBERRY
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MISS
Other - First Name:DONNA
Other - Middle Name:JEAN
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6510 S FOUNTAIN PL
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98178-2555
Mailing Address - Country:US
Mailing Address - Phone:206-794-4574
Mailing Address - Fax:
Practice Address - Street 1:6510 S FOUNTAIN PL
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98178-2555
Practice Address - Country:US
Practice Address - Phone:206-794-4574
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-24
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW 000094031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical