Healthcare Provider Details

I. General information

NPI: 1679357032
Provider Name (Legal Business Name): MATTHEW PAUL NICKEL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2023
Last Update Date: 08/24/2023
Certification Date: 08/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2075 W BIG BEAVER RD STE 520
TROY MI
48084-3442
US

IV. Provider business mailing address

2075 W BIG BEAVER RD STE 520
TROY MI
48084-3442
US

V. Phone/Fax

Practice location:
  • Phone: 248-646-6659
  • Fax:
Mailing address:
  • Phone: 248-646-6659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number6362009788
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code103TF0000X
TaxonomyFamily Psychologist
License Number6362009788
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code103TA0700X
TaxonomyAdult Development & Aging Psychologist
License Number6362009788
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number6362009788
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License Number6362009788
License Number StateMI
# 6
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number6362009788
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: