Provider Demographics
NPI:1235938796
Name:NICKERSON, ANDREW (EDS, NCSP, LEP)
Entity type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:
Credentials:EDS, NCSP, LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 OAKRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:HOLDEN
Mailing Address - State:MA
Mailing Address - Zip Code:01520-1626
Mailing Address - Country:US
Mailing Address - Phone:207-956-2725
Mailing Address - Fax:
Practice Address - Street 1:15 OAKRIDGE RD
Practice Address - Street 2:
Practice Address - City:HOLDEN
Practice Address - State:MA
Practice Address - Zip Code:01520-1626
Practice Address - Country:US
Practice Address - Phone:207-956-2725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-10
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALEP10000153103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool