Provider Demographics
NPI:1972223923
Name:FRY, NICHOLAS ROBERT
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:ROBERT
Last Name:FRY
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 1:1880 OFFICE CLUB PT STE 124
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80920-5012
Mailing Address - Country:US
Mailing Address - Phone:719-357-6580
Mailing Address - Fax:
Practice Address - Street 1:1880 OFFICE CLUB PT STE 124
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-5012
Practice Address - Country:US
Practice Address - Phone:719-357-6580
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-30
Last Update Date:2024-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCSW.09928253101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health