Provider Demographics
NPI:1922268093
Name:WAHL, NICHOLAS R (MA LPC)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:R
Last Name:WAHL
Suffix:
Gender:M
Credentials:MA LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2521 E MOUNTAIN VILLAGE DR # B-250
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7373
Mailing Address - Country:US
Mailing Address - Phone:907-317-0012
Mailing Address - Fax:907-357-2104
Practice Address - Street 1:1075 S CHECK ST STE 207
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-8067
Practice Address - Country:US
Practice Address - Phone:907-317-0012
Practice Address - Fax:907-357-2104
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-12
Last Update Date:2020-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK556101YP2500X
AKPCOP556101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional