Provider Demographics
NPI:1558383000
Name:GAMMELLO, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:GAMMELLO
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 1:11636 FAIRWAY RD
Mailing Address - Street 2:
Mailing Address - City:EAST GULL LAKE
Mailing Address - State:MN
Mailing Address - Zip Code:56401-2099
Mailing Address - Country:US
Mailing Address - Phone:218-838-4209
Mailing Address - Fax:
Practice Address - Street 1:18510 STATE HIGHWAY 371 STE D
Practice Address - Street 2:
Practice Address - City:BRAINERD
Practice Address - State:MN
Practice Address - Zip Code:56401-6996
Practice Address - Country:US
Practice Address - Phone:218-838-4209
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1437103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN62Q99GAOtherBLUE CROSS
MN731353500Medicaid