Provider Demographics
NPI:1063409852
Name:NICHOLS, DAVID L (PHD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:L
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 DURAND AVE STE 600
Mailing Address - Street 2:
Mailing Address - City:STURTEVANT
Mailing Address - State:WI
Mailing Address - Zip Code:53177-2096
Mailing Address - Country:US
Mailing Address - Phone:262-635-5520
Mailing Address - Fax:262-635-5530
Practice Address - Street 1:8700 DURAND AVE STE 600
Practice Address - Street 2:
Practice Address - City:STURTEVANT
Practice Address - State:WI
Practice Address - Zip Code:53177-2096
Practice Address - Country:US
Practice Address - Phone:262-635-5520
Practice Address - Fax:262-635-5530
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI943-057103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39027600Medicaid