Provider Demographics
NPI:1952933608
Name:CARMODY, NICHOLAUS LEO
Entity type:Individual
Prefix:
First Name:NICHOLAUS
Middle Name:LEO
Last Name:CARMODY
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 1:29451 FALCON RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:EVERGREEN
Mailing Address - State:CO
Mailing Address - Zip Code:80439-6564
Mailing Address - Country:US
Mailing Address - Phone:720-587-9499
Mailing Address - Fax:
Practice Address - Street 1:29451 FALCON RIDGE DR
Practice Address - Street 2:
Practice Address - City:EVERGREEN
Practice Address - State:CO
Practice Address - Zip Code:80439-6564
Practice Address - Country:US
Practice Address - Phone:720-587-9499
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-02-11
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health