Provider Demographics
NPI:1750318374
Name:NICHTA, LAWRENCE J JR (PH D)
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:J
Last Name:NICHTA
Suffix:JR
Gender:M
Credentials:PH D
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2120 SOUTH GREEN ROAD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:SOUTH EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44121-3317
Mailing Address - Country:US
Mailing Address - Phone:216-381-1113
Mailing Address - Fax:
Practice Address - Street 1:2120 SOUTH GREEN ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:SOUTH EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44121-3317
Practice Address - Country:US
Practice Address - Phone:216-381-1113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-27
Last Update Date:2012-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4435103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHCP11975Medicare PIN