Provider Demographics
NPI:1821503640
Name:FARRELL, NICHOLAS R
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:R
Last Name:FARRELL
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 1:34700 VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:OCONOMOWOC
Mailing Address - State:WI
Mailing Address - Zip Code:53066-4500
Mailing Address - Country:US
Mailing Address - Phone:800-767-4411
Mailing Address - Fax:262-646-1049
Practice Address - Street 1:34700 VALLEY RD
Practice Address - Street 2:
Practice Address - City:OCONOMOWOC
Practice Address - State:WI
Practice Address - Zip Code:53066-4500
Practice Address - Country:US
Practice Address - Phone:800-767-4411
Practice Address - Fax:262-646-3158
Is Sole Proprietor?:No
Enumeration Date:2017-12-04
Last Update Date:2017-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3525103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist