Healthcare Provider Details

I. General information

NPI: 1083350482
Provider Name (Legal Business Name): NASHLYN GRACE VIDRICKSEN LMLP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 W BROADWAY ST
NEWTON KS
67114-2004
US

IV. Provider business mailing address

900 W BROADWAY ST
NEWTON KS
67114-2004
US

V. Phone/Fax

Practice location:
  • Phone: 316-283-1950
  • Fax: 316-529-9351
Mailing address:
  • Phone: 316-283-1950
  • Fax: 316-529-9351

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberLMLP03366
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: