Provider Demographics
NPI:1558876896
Name:NICHOLLS, BENJAMIN J (DPT)
Entity Type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:J
Last Name:NICHOLLS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1421 N 7275 E
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84317-9615
Mailing Address - Country:US
Mailing Address - Phone:801-745-3200
Mailing Address - Fax:801-745-6115
Practice Address - Street 1:2131 N 5500 E
Practice Address - Street 2:
Practice Address - City:EDEN
Practice Address - State:UT
Practice Address - Zip Code:84310-9856
Practice Address - Country:US
Practice Address - Phone:801-745-3200
Practice Address - Fax:801-745-6115
Is Sole Proprietor?:No
Enumeration Date:2017-12-08
Last Update Date:2022-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
UT8572509-2401225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist