Provider Demographics
NPI:1235621020
Name:NICHOLS, BRANDON (LBA)
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 MORSE MEMORIAL HWY
Mailing Address - Street 2:
Mailing Address - City:OLMSTEDVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12857-1825
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:571 MORSE MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:OLMSTEDVILLE
Practice Address - State:NY
Practice Address - Zip Code:12857-1825
Practice Address - Country:US
Practice Address - Phone:607-434-5134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000559103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst