Provider Demographics
NPI:1598583833
Name:NICKLES, KERRI LAUREN (EDS)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:LAUREN
Last Name:NICKLES
Suffix:
Gender:F
Credentials:EDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:825 E 075 N
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-2099
Mailing Address - Country:US
Mailing Address - Phone:260-499-2400
Mailing Address - Fax:
Practice Address - Street 1:825 E 075 N
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761-9360
Practice Address - Country:US
Practice Address - Phone:260-499-2400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN10322352103TS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool