Provider Demographics
NPI:1689705253
Name:NICHOLS, STEPHEN GRANT (MPT)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:GRANT
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:641 HOY RD
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39443-0912
Mailing Address - Country:US
Mailing Address - Phone:601-433-5926
Mailing Address - Fax:
Practice Address - Street 1:140 EUREKA STREET
Practice Address - Street 2:
Practice Address - City:TAYLORSVILLE
Practice Address - State:MS
Practice Address - Zip Code:39168
Practice Address - Country:US
Practice Address - Phone:601-785-9292
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPT3150225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist