Provider Demographics
NPI:1821537390
Name:NICHOLSON, SCOTT CRANDALL
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:CRANDALL
Last Name:NICHOLSON
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 1:901 E CRESTVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4759
Mailing Address - Country:US
Mailing Address - Phone:928-853-0937
Mailing Address - Fax:
Practice Address - Street 1:1300 S MILTON RD
Practice Address - Street 2:#206
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-7302
Practice Address - Country:US
Practice Address - Phone:928-774-8407
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2017-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZMT-030789225700000X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer