Provider Demographics
NPI:1902944317
Name:NICHOLSON, CHARMAINE L (MA, LCPC)
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:L
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MA, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5705 62ND AVE SW
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59404-5244
Mailing Address - Country:US
Mailing Address - Phone:406-771-7280
Mailing Address - Fax:
Practice Address - Street 1:1324 CENTRAL AVE W # 14
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59404-3971
Practice Address - Country:US
Practice Address - Phone:406-788-1977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT488LCPC101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT074896OtherLCPC BLUE CROSS
MT250240Medicaid