Provider Demographics
NPI:1750649265
Name:NICHOLS, DEANNA R (LCMHC, RDN)
Entity Type:Individual
Prefix:MRS
First Name:DEANNA
Middle Name:R
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:LCMHC, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1791 E MULE DEER DR
Mailing Address - Street 2:
Mailing Address - City:DRAPER
Mailing Address - State:UT
Mailing Address - Zip Code:84020-5625
Mailing Address - Country:US
Mailing Address - Phone:801-580-0552
Mailing Address - Fax:
Practice Address - Street 1:11075 S STATE ST STE 14
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84070-5194
Practice Address - Country:US
Practice Address - Phone:801-580-0552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-03
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT278841-6004101Y00000X
UT278841-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered