Provider Demographics
NPI:1518350222
Name:NICHOLAS, ETHAN (LCSW, LAC, LMSW)
Entity type:Individual
Prefix:
First Name:ETHAN
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:LCSW, LAC, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2005 TOWN CENTER BLVD UNIT 3441
Mailing Address - Street 2:
Mailing Address - City:ODENTON
Mailing Address - State:MD
Mailing Address - Zip Code:21113-1780
Mailing Address - Country:US
Mailing Address - Phone:985-227-3897
Mailing Address - Fax:
Practice Address - Street 1:2480 LLEWELLYN AVE
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20755-7081
Practice Address - Country:US
Practice Address - Phone:301-677-8895
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-05
Last Update Date:2024-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1548101YA0400X
LA12901104100000X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker