Healthcare Provider Details

I. General information

NPI: 1265464630
Provider Name (Legal Business Name): WYATT LEE NICHOLS PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 08/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8142 COUNTRY VILLAGE DR STE 102
CORDOVA TN
38016-2029
US

IV. Provider business mailing address

8142 COUNTRY VILLAGE DR STE 102
CORDOVA TN
38016-2029
US

V. Phone/Fax

Practice location:
  • Phone: 901-388-1893
  • Fax: 901-388-1995
Mailing address:
  • Phone: 901-388-1893
  • Fax: 901-388-1995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TF0200X
TaxonomyForensic Psychologist
License NumberP866
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP866
License Number StateTN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: