Provider Demographics
NPI:1073605614
Name:NICHOLS, SHANA (PHD)
Entity Type:Individual
Prefix:
First Name:SHANA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 OLD EAST NECK RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:63 OLD EAST NECK RD
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-2806
Practice Address - Country:US
Practice Address - Phone:631-923-0923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-29
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY016634103T00000X
CO2951103TC0700X
MO2011000658103TC0700X
IA001285103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical