Provider Demographics
NPI:1265500987
Name:NICKESON, CARL (PHD)
Entity Type:Individual
Prefix:DR
First Name:CARL
Middle Name:
Last Name:NICKESON
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 1:1635 E ROBINSON ST
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32803-5932
Mailing Address - Country:US
Mailing Address - Phone:407-898-8544
Mailing Address - Fax:407-898-9384
Practice Address - Street 1:1635 E ROBINSON ST
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32803-5932
Practice Address - Country:US
Practice Address - Phone:407-898-8544
Practice Address - Fax:407-898-9384
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY2477103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL75098Medicare ID - Type Unspecified