Healthcare Provider Details

I. General information

NPI: 1053139808
Provider Name (Legal Business Name): NICKOLAUS H GASTIL PSYCH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2024
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

645 S ROGERS ST
BLOOMINGTON IN
47403-2353
US

IV. Provider business mailing address

4645 BELLSVILLE PIKE
NASHVILLE IN
47448-9090
US

V. Phone/Fax

Practice location:
  • Phone: 812-314-3400
  • Fax: 812-337-2438
Mailing address:
  • Phone: 812-320-8109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number20043859A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: