Provider Demographics
NPI:1982139903
Name:NICKL, KAREN LOUISE (PHD PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:KAREN
Middle Name:LOUISE
Last Name:NICKL
Suffix:
Gender:F
Credentials:PHD PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:415 MEDICAL DR
Mailing Address - Street 2:SUITE B101
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-4946
Mailing Address - Country:US
Mailing Address - Phone:801-703-4473
Mailing Address - Fax:
Practice Address - Street 1:415 MEDICAL DR
Practice Address - Street 2:SUITE B101
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-4946
Practice Address - Country:US
Practice Address - Phone:801-703-4473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-27
Last Update Date:2017-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT5204774-2501103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist