Provider Demographics
NPI:1124429840
Name:NICKELS, MARK THOMAS
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:THOMAS
Last Name:NICKELS
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 1:96 SOUTH ST
Mailing Address - Street 2:WARE
Mailing Address - City:WARE
Mailing Address - State:MA
Mailing Address - Zip Code:01082-1616
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:96 SOUTH ST
Practice Address - Street 2:WARE
Practice Address - City:WARE
Practice Address - State:MA
Practice Address - Zip Code:01082-1616
Practice Address - Country:US
Practice Address - Phone:413-967-6241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-12
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA11077101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1300881Medicaid