Provider Demographics
NPI:1831745223
Name:NOWICKE, CLINTON M (PSYCHOLOGY ASSISTANT)
Entity type:Individual
Prefix:
First Name:CLINTON
Middle Name:M
Last Name:NOWICKE
Suffix:
Gender:M
Credentials:PSYCHOLOGY ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 776879
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6879
Mailing Address - Country:US
Mailing Address - Phone:502-559-9425
Mailing Address - Fax:502-272-5339
Practice Address - Street 1:3840 RUCKRIEGEL PKWY STE 105
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-6836
Practice Address - Country:US
Practice Address - Phone:502-261-7227
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-13
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY277977103TC0700X
103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist