Provider Demographics
NPI:1366924094
Name:NICKEL, UTAH (MS, BACB, LABA)
Entity type:Individual
Prefix:MR
First Name:UTAH
Middle Name:
Last Name:NICKEL
Suffix:
Gender:M
Credentials:MS, BACB, LABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 LOCUST ST
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746-1337
Mailing Address - Country:US
Mailing Address - Phone:508-282-9817
Mailing Address - Fax:
Practice Address - Street 1:330 SW CUTOFF STE 203
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-2730
Practice Address - Country:US
Practice Address - Phone:508-341-2829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-29
Last Update Date:2018-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician