Provider Demographics
NPI:1588643852
Name:NICHOLAS, PETER MICHAEL (LCSW)
Entity Type:Individual
Prefix:DR
First Name:PETER
Middle Name:MICHAEL
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:780 GUARDSMAN WAY
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1374
Mailing Address - Country:US
Mailing Address - Phone:801-581-0194
Mailing Address - Fax:801-581-0193
Practice Address - Street 1:780 GUARDSMAN WAY
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84108-1374
Practice Address - Country:US
Practice Address - Phone:801-581-0194
Practice Address - Fax:801-581-0193
Is Sole Proprietor?:No
Enumeration Date:2006-01-13
Last Update Date:2008-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11925635011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT289948OtherDESERET MUTUAL
UT107001279101OtherINTERMOUNTAIN HEALTH CARE
UT942938348NI1OtherEDUCATOR'S MUTUAL