Provider Demographics
NPI:1407470644
Name:NICHOLS, LINDSAY C (MA)
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:C
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9666 OLIVE BLVD STE 370
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63132-3025
Mailing Address - Country:US
Mailing Address - Phone:314-499-1060
Mailing Address - Fax:
Practice Address - Street 1:9666 OLIVE BLVD STE 370
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63132-3025
Practice Address - Country:US
Practice Address - Phone:314-449-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-03
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20200102345101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO994664654Medicaid