Provider Demographics
NPI:1609362284
Name:ETCHISON, NICHOLAS DAVID
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:DAVID
Last Name:ETCHISON
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 1:1026 CROMWELL BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21286-3318
Mailing Address - Country:US
Mailing Address - Phone:410-583-1515
Mailing Address - Fax:
Practice Address - Street 1:1026 CROMWELL BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21286
Practice Address - Country:US
Practice Address - Phone:410-583-1515
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-06
Last Update Date:2018-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician