Provider Demographics
NPI:1093447948
Name:NICHOLAS, GABRYEL
Entity Type:Individual
Prefix:
First Name:GABRYEL
Middle Name:
Last Name:NICHOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3340 S LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IN
Mailing Address - Zip Code:46953-4501
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3340 S LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953-4501
Practice Address - Country:US
Practice Address - Phone:765-661-9709
Practice Address - Fax:765-573-6769
Is Sole Proprietor?:No
Enumeration Date:2022-06-29
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician