Provider Demographics
NPI:1942567557
Name:MCNICHOLAS, MICHAEL T
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:T
Last Name:MCNICHOLAS
Suffix:
Gender:M
Credentials:
Other - Prefix:MR
Other - First Name:MICHAEL
Other - Middle Name:T
Other - Last Name:MCNICHOLAS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:7052 SW NYBERG ST
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062-9231
Mailing Address - Country:US
Mailing Address - Phone:503-766-3366
Mailing Address - Fax:503-766-3366
Practice Address - Street 1:7052 SW NYBERG ST
Practice Address - Street 2:
Practice Address - City:TUALATIN
Practice Address - State:OR
Practice Address - Zip Code:97062-9231
Practice Address - Country:US
Practice Address - Phone:503-766-3366
Practice Address - Fax:503-766-3366
Is Sole Proprietor?:No
Enumeration Date:2012-04-19
Last Update Date:2012-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17929225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist