Provider Demographics
NPI:1932378270
Name:MICHAEL A. NICHOLAS PHD PLLC
Entity Type:Organization
Organization Name:MICHAEL A. NICHOLAS PHD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:RAYCHAL
Authorized Official - Middle Name:D
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-408-4192
Mailing Address - Street 1:PO BOX 7723
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42002-7723
Mailing Address - Country:US
Mailing Address - Phone:270-408-4192
Mailing Address - Fax:
Practice Address - Street 1:100 FOUNTAIN AVE
Practice Address - Street 2:SUITE 220
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42001-2771
Practice Address - Country:US
Practice Address - Phone:270-408-4192
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY850103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103G00000XBehavioral Health & Social Service ProvidersClinical NeuropsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY00612001Medicare PIN