Provider Demographics
NPI:1477630986
Name:NICHELSON, BRIAN (PHD, HSPP)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:NICHELSON
Suffix:
Gender:M
Credentials:PHD, HSPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 W JEFFERSON ST
Mailing Address - Street 2:SUITE C
Mailing Address - City:FRANKLIN
Mailing Address - State:IN
Mailing Address - Zip Code:46131-9121
Mailing Address - Country:US
Mailing Address - Phone:317-736-8474
Mailing Address - Fax:317-736-6040
Practice Address - Street 1:1300 W JEFFERSON ST
Practice Address - Street 2:SUITE C
Practice Address - City:FRANKLIN
Practice Address - State:IN
Practice Address - Zip Code:46131-9121
Practice Address - Country:US
Practice Address - Phone:317-736-8474
Practice Address - Fax:317-736-6040
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2014-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20040652103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100194240Medicaid
IN151560LLLLMedicare PIN
IN100194240Medicaid
IN151560LLLLMedicare PIN
680012485Medicare PIN