Provider Demographics
NPI:1285629493
Name:NILLES, NANCI ROTH (PSYD)
Entity Type:Individual
Prefix:
First Name:NANCI
Middle Name:ROTH
Last Name:NILLES
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2134 MARY SHERMAN DR
Mailing Address - Street 2:
Mailing Address - City:SULLIVAN
Mailing Address - State:IN
Mailing Address - Zip Code:47882-7625
Mailing Address - Country:US
Mailing Address - Phone:812-268-6376
Mailing Address - Fax:812-268-6377
Practice Address - Street 1:2134 MARY SHERMAN DR
Practice Address - Street 2:
Practice Address - City:SULLIVAN
Practice Address - State:IN
Practice Address - Zip Code:47882-7625
Practice Address - Country:US
Practice Address - Phone:812-268-6376
Practice Address - Fax:812-268-6377
Is Sole Proprietor?:No
Enumeration Date:2005-09-14
Last Update Date:2011-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20041814A103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200396290Medicaid
IN200396290Medicaid