Provider Demographics
NPI:1245748540
Name:NYMAN, MICHAEL
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:NYMAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 GIBBON ST
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22314-4132
Mailing Address - Country:US
Mailing Address - Phone:732-492-4803
Mailing Address - Fax:
Practice Address - Street 1:400 GIBBON ST
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22314-4132
Practice Address - Country:US
Practice Address - Phone:732-492-4803
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-21
Last Update Date:2019-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TS0200X
1-17-28652103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool