Provider Demographics
NPI:1265464630
Name:NICHOLS, WYATT LEE (PHD)
Entity Type:Individual
Prefix:DR
First Name:WYATT
Middle Name:LEE
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8142 COUNTRY VILLAGE DR STE 102
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38016-2029
Mailing Address - Country:US
Mailing Address - Phone:901-388-1893
Mailing Address - Fax:901-388-1995
Practice Address - Street 1:8142 COUNTRY VILLAGE DR STE 102
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016-2029
Practice Address - Country:US
Practice Address - Phone:901-388-1893
Practice Address - Fax:901-388-1995
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2018-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNP866103TF0200X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3687475Medicare ID - Type Unspecified