Provider Demographics
NPI:1689781247
Name:NICHOLS, DAVID C (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:C
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 DRAKE LN
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-7414
Mailing Address - Country:US
Mailing Address - Phone:207-858-2961
Mailing Address - Fax:603-679-2048
Practice Address - Street 1:345 COTTAGE RD
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-3919
Practice Address - Country:US
Practice Address - Phone:207-858-2961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH605103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NHRE1839Medicare PIN
MEE300267787Medicare PIN