Provider Demographics
NPI:1407854292
Name:NOLL, NICHOLAS (PHD)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:NOLL
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 1:1208 NE 97TH ST
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64155-2109
Mailing Address - Country:US
Mailing Address - Phone:816-835-9882
Mailing Address - Fax:
Practice Address - Street 1:1208 NE 97TH ST
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64155-2109
Practice Address - Country:US
Practice Address - Phone:816-835-9882
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPYR0288103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Not Answered103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP782727Medicare ID - Type Unspecified