Provider Demographics
NPI:1255811261
Name:NICHOLAS, MICAH CHARLES (BA)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:CHARLES
Last Name:NICHOLAS
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 CENTER ST STE A
Mailing Address - Street 2:
Mailing Address - City:NEW IBERIA
Mailing Address - State:LA
Mailing Address - Zip Code:70560-5500
Mailing Address - Country:US
Mailing Address - Phone:337-551-4630
Mailing Address - Fax:
Practice Address - Street 1:825 CENTER ST
Practice Address - Street 2:
Practice Address - City:NEW IBERIA
Practice Address - State:LA
Practice Address - Zip Code:70560
Practice Address - Country:US
Practice Address - Phone:337-551-4630
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-19
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X171M00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator