Provider Demographics
NPI:1538495692
Name:NICHOLS, MARTI LEEANN (LBHP)
Entity Type:Individual
Prefix:
First Name:MARTI
Middle Name:LEEANN
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LBHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 S WHITAKER ST
Mailing Address - Street 2:
Mailing Address - City:PRYOR
Mailing Address - State:OK
Mailing Address - Zip Code:74361-3424
Mailing Address - Country:US
Mailing Address - Phone:918-864-0353
Mailing Address - Fax:
Practice Address - Street 1:205 S ADAIR ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-5201
Practice Address - Country:US
Practice Address - Phone:918-825-4872
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-26
Last Update Date:2012-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
103TR0400X
OK103TA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TA0400XBehavioral Health & Social Service ProvidersPsychologistAddiction (Substance Use Disorder)
No103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200375130AMedicaid