Provider Demographics
NPI:1437180130
Name:NICHOLS, MICHAEL LEE (MSW)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:LEE
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 N GRACE AVENUE CT
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:KS
Mailing Address - Zip Code:67002-9594
Mailing Address - Country:US
Mailing Address - Phone:316-733-9676
Mailing Address - Fax:
Practice Address - Street 1:200 W DOUGLAS AVE
Practice Address - Street 2:SUITE #560
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67202-3013
Practice Address - Country:US
Practice Address - Phone:316-269-2322
Practice Address - Fax:316-269-2448
Is Sole Proprietor?:No
Enumeration Date:2006-07-05
Last Update Date:2007-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KSLSCSW 15891041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS071074Medicare PIN