Provider Demographics
NPI:1730763087
Name:NICHOLSON, AUDRIE M (LCSW)
Entity type:Individual
Prefix:
First Name:AUDRIE
Middle Name:M
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:192 GRANT HWY
Mailing Address - Street 2:
Mailing Address - City:GORDONSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38563-4550
Mailing Address - Country:US
Mailing Address - Phone:615-594-5490
Mailing Address - Fax:
Practice Address - Street 1:1314 MAIN ST N
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TN
Practice Address - Zip Code:37030-1054
Practice Address - Country:US
Practice Address - Phone:615-594-5490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-11
Last Update Date:2024-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW00000085051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNLSW0000008505OtherBOARD OF SOCIAL WORKER LICENSURE