Provider Demographics
NPI:1679170575
Name:NICKERSON, WENDY DIANE (LCSW)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:DIANE
Last Name:NICKERSON
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 1:741 S 2ND ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19147-3425
Mailing Address - Country:US
Mailing Address - Phone:610-256-7321
Mailing Address - Fax:
Practice Address - Street 1:741 S 2ND ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19147-3425
Practice Address - Country:US
Practice Address - Phone:610-256-7321
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-04
Last Update Date:2020-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0212281041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical