Provider Demographics
NPI:1508996786
Name:NICHOLS, MELISSA GRACE
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:GRACE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18322 MINNETONKA BLVD STE C
Mailing Address - Street 2:
Mailing Address - City:WAYZATA
Mailing Address - State:MN
Mailing Address - Zip Code:55391-3258
Mailing Address - Country:US
Mailing Address - Phone:952-475-2818
Mailing Address - Fax:952-475-3356
Practice Address - Street 1:18322 MINNETONKA BLVD STE C
Practice Address - Street 2:
Practice Address - City:WAYZATA
Practice Address - State:MN
Practice Address - Zip Code:55391-3258
Practice Address - Country:US
Practice Address - Phone:952-475-2818
Practice Address - Fax:952-475-3356
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1058106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist