Provider Demographics
NPI:1669737201
Name:WEATHERLY, NICHOLAS L
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:L
Last Name:WEATHERLY
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 1:4002 SPRINGHILL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40207-4518
Mailing Address - Country:US
Mailing Address - Phone:502-473-7219
Mailing Address - Fax:502-473-7315
Practice Address - Street 1:4002 SPRINGHILL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4518
Practice Address - Country:US
Practice Address - Phone:502-473-7219
Practice Address - Fax:502-473-7315
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-10
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1062794103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst