Provider Demographics
NPI:1790019511
Name:NICKOLS, RILEY
Entity Type:Individual
Prefix:
First Name:RILEY
Middle Name:
Last Name:NICKOLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16 N GORE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63119-2315
Mailing Address - Country:US
Mailing Address - Phone:513-505-2160
Mailing Address - Fax:
Practice Address - Street 1:231 W LOCKWOOD AVE
Practice Address - Street 2:SUITE 201
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63119-2951
Practice Address - Country:US
Practice Address - Phone:314-968-1900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-25
Last Update Date:2020-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013032493103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist