Provider Demographics
NPI:1528314713
Name:NICHOLS, GARY W (MDIV)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:W
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:MDIV
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5150 E STOP 11 RD STE 10
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46237-8629
Mailing Address - Country:US
Mailing Address - Phone:317-881-0409
Mailing Address - Fax:317-881-6450
Practice Address - Street 1:5150 E STOP 11 RD STE 10
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-8629
Practice Address - Country:US
Practice Address - Phone:317-881-0409
Practice Address - Fax:317-881-6450
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-25
Last Update Date:2012-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral