Provider Demographics
NPI:1184063372
Name:NICHOLS, AXTON TYLER
Entity type:Individual
Prefix:MR
First Name:AXTON
Middle Name:TYLER
Last Name:NICHOLS
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 1:2619 N HARVEY AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73103-3017
Mailing Address - Country:US
Mailing Address - Phone:405-525-3959
Mailing Address - Fax:
Practice Address - Street 1:2619 N HARVEY AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73103-3017
Practice Address - Country:US
Practice Address - Phone:405-525-3959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-20
Last Update Date:2013-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health