Provider Demographics
NPI:1952473647
Name:NICHOLS, JOHN ARTHUR (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ARTHUR
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4 RUMFORD RD
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02420-2209
Mailing Address - Country:US
Mailing Address - Phone:617-484-1042
Mailing Address - Fax:
Practice Address - Street 1:113 BELMONT ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-3603
Practice Address - Country:US
Practice Address - Phone:617-484-1042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-15
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4101103TC0700X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA169987000OtherMAGELLAN HEALTH
MA712923OtherTUFTS HEALTH PLAN
MAW04075OtherBLUE CROSS AND BLUE SHIEL
MAW04075OtherBLUE CROSS AND BLUE SHIEL