Provider Demographics
NPI:1588794069
Name:NICHOLS, CYNTHIA (PHD)
Entity type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 MUNSON AVE
Mailing Address - Street 2:STE. 201
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3580
Mailing Address - Country:US
Mailing Address - Phone:231-935-9307
Mailing Address - Fax:231-935-9300
Practice Address - Street 1:550 MUNSON AVE
Practice Address - Street 2:STE. 201
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3580
Practice Address - Country:US
Practice Address - Phone:231-935-9307
Practice Address - Fax:231-935-9300
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2018-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301008026103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MICN008026OtherBLUE CROSS
MIS69451Medicare UPIN