Provider Demographics
NPI:1942331368
Name:NICHOLSON PSYCHOPHYSIOLOGICAL REHAB
Entity Type:Organization
Organization Name:NICHOLSON PSYCHOPHYSIOLOGICAL REHAB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ELAINE
Authorized Official - Middle Name:RUTHE
Authorized Official - Last Name:NICHOLSON
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:520-722-2892
Mailing Address - Street 1:PO BOX 30755
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85751-0755
Mailing Address - Country:US
Mailing Address - Phone:520-722-2892
Mailing Address - Fax:520-722-2873
Practice Address - Street 1:5956 E PIMA ST
Practice Address - Street 2:SUITE 130
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712
Practice Address - Country:US
Practice Address - Phone:520-722-2892
Practice Address - Fax:520-722-2873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-08
Last Update Date:2008-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ0857103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ70145Medicare PIN