Provider Demographics
NPI:1508557950
Name:MCNICKLE, TIMOTHY ARTHUR
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:ARTHUR
Last Name:MCNICKLE
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 1:5250 JEANNE LYNN AVE
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44514-1322
Mailing Address - Country:US
Mailing Address - Phone:330-565-7889
Mailing Address - Fax:
Practice Address - Street 1:5250 JEANNE LYNN AVE
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44514-1322
Practice Address - Country:US
Practice Address - Phone:330-565-7889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health