Provider Demographics
NPI:1902333198
Name:NICHOLS, MAVERICK RAY (DPT)
Entity type:Individual
Prefix:MR
First Name:MAVERICK
Middle Name:RAY
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3073 SHIRLEY DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-7010
Mailing Address - Country:US
Mailing Address - Phone:517-990-6210
Mailing Address - Fax:517-990-6212
Practice Address - Street 1:5100 MARSH RD STE G
Practice Address - Street 2:
Practice Address - City:OKEMOS
Practice Address - State:MI
Practice Address - Zip Code:48864-1195
Practice Address - Country:US
Practice Address - Phone:517-220-4540
Practice Address - Fax:517-220-4652
Is Sole Proprietor?:No
Enumeration Date:2017-05-18
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501018201225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C33041OtherBCBS