Healthcare Provider Details

I. General information

NPI: 1396006003
Provider Name (Legal Business Name): MELISSA SUE NICHOLS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2012
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

950 SOUTH 663 WEST
BRIGHAM CITY UT
84302-2400
US

IV. Provider business mailing address

90 E 200 N
LOGAN UT
84321-4034
US

V. Phone/Fax

Practice location:
  • Phone: 435-257-2168
  • Fax:
Mailing address:
  • Phone: 435-752-0750
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8957395-3502
License Number StateUT

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: