Provider Demographics
NPI:1114493046
Name:NICHOLS, SHANNON RAYE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:RAYE
Last Name:NICHOLS
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 1:1408 SWEET HOME RD
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14228-2783
Mailing Address - Country:US
Mailing Address - Phone:716-247-5281
Mailing Address - Fax:716-204-0670
Practice Address - Street 1:1408 SWEET HOME RD
Practice Address - Street 2:
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14228-2783
Practice Address - Country:US
Practice Address - Phone:716-247-5281
Practice Address - Fax:716-204-0670
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor