Provider Demographics
NPI:1497405013
Name:NICHOLSON, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:NICHOLSON
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 1:3415 GILMER CT APT C
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36105-2324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3415 GILMER CT APT C
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36105-2324
Practice Address - Country:US
Practice Address - Phone:304-254-6499
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-26
Last Update Date:2022-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TP0814XBehavioral Health & Social Service ProvidersPsychologistPsychoanalysis
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL10374773OtherLICENSE NO