Individual
KENNETH R NICHOLS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
LCSW
Contact information
Practice address
1001 W BROADWAY STE D, FARMINGTON, NM 87401-5638
(505) 325-0238
Mailing address
819 N WATSON AVE, FARMINGTON, NM 87401-9127
(253) 427-0881
Taxonomy
Speciality
Code
Description
License number
State
1041C0700X
Clinical Social Worker
Primary
C-11080
NM
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1619475944
—
NM
05
—
1649724055
—
NM
Enumeration date
01/26/2017
Last updated
08/31/2020
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