Provider Demographics
NPI:1629137880
Name:ANTHONY, NICHOLAS CHARLES
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:CHARLES
Last Name:ANTHONY
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 1:905 HIGHLAND BLVD
Mailing Address - Street 2:STE. 4500
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-6901
Mailing Address - Country:US
Mailing Address - Phone:406-551-0533
Mailing Address - Fax:
Practice Address - Street 1:905 HIGHLAND BLVD
Practice Address - Street 2:STE. 4500
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-6901
Practice Address - Country:US
Practice Address - Phone:406-551-0533
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY 3960103TC0700X
MTPSY-PSY-LIC 1484103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL73841Medicare ID - Type Unspecified