Provider Demographics
NPI:1417237462
Name:NICHOLS, TED WAYNE
Entity Type:Individual
Prefix:
First Name:TED
Middle Name:WAYNE
Last Name:NICHOLS
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 1:7823 DAIRY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MEBANE
Mailing Address - State:NC
Mailing Address - Zip Code:27302-9281
Mailing Address - Country:US
Mailing Address - Phone:919-563-1927
Mailing Address - Fax:
Practice Address - Street 1:7823 DAIRY RIDGE RD
Practice Address - Street 2:
Practice Address - City:MEBANE
Practice Address - State:NC
Practice Address - Zip Code:27302-9281
Practice Address - Country:US
Practice Address - Phone:919-563-1927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-23
Last Update Date:2011-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0717000648106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist