Provider Demographics
NPI:1467471565
Name:NICHOLAS, MICHAEL A (PHD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:A
Last Name:NICHOLAS
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:PO BOX 7223
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7223
Mailing Address - Country:US
Mailing Address - Phone:270-408-4192
Mailing Address - Fax:270-443-1784
Practice Address - Street 1:100 FOUNTAIN AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-2771
Practice Address - Country:US
Practice Address - Phone:270-408-4192
Practice Address - Fax:270-443-1784
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY850103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00612001Medicare PIN