Provider Demographics
NPI:1629419437
Name:NICHOLSON, TIMOTHY I (PLPC)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:I
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:PLPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1323 SULLIVAN AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63107-3919
Mailing Address - Country:US
Mailing Address - Phone:314-265-7014
Mailing Address - Fax:
Practice Address - Street 1:1323 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63107-3919
Practice Address - Country:US
Practice Address - Phone:314-265-7014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012006798101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional