Provider Demographics
NPI:1790259802
Name:NICHOLS, KASEY
Entity Type:Individual
Prefix:
First Name:KASEY
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8229 CLOVERLEAF DR STE 425
Mailing Address - Street 2:
Mailing Address - City:MILLERSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21108-1594
Mailing Address - Country:US
Mailing Address - Phone:410-541-6612
Mailing Address - Fax:
Practice Address - Street 1:8229 CLOVERLEAF DR STE 425
Practice Address - Street 2:
Practice Address - City:MILLERSVILLE
Practice Address - State:MD
Practice Address - Zip Code:21108-1594
Practice Address - Country:US
Practice Address - Phone:541-554-9777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-11
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLGP9102101Y00000X
MDLC11955101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101Y00000XBehavioral Health & Social Service ProvidersCounselor