Provider Demographics
NPI:1861254575
Name:NICHOLAS, LIBERTY LOUISE (LCSW)
Entity type:Individual
Prefix:
First Name:LIBERTY
Middle Name:LOUISE
Last Name:NICHOLAS
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 1:15514 RIVER BND
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247-2919
Mailing Address - Country:US
Mailing Address - Phone:512-596-5805
Mailing Address - Fax:
Practice Address - Street 1:15514 RIVER BND
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247-2919
Practice Address - Country:US
Practice Address - Phone:210-685-0711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-29
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX558611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX99-4129751OtherPRIVATE THERAPY PRACTICE