Healthcare Provider Details

I. General information

NPI: 1245748540
Provider Name (Legal Business Name): MICHAEL NYMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2018
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 GIBBON ST
ALEXANDRIA VA
22314-4132
US

IV. Provider business mailing address

400 GIBBON ST
ALEXANDRIA VA
22314-4132
US

V. Phone/Fax

Practice location:
  • Phone: 732-492-4803
  • Fax:
Mailing address:
  • Phone: 732-492-4803
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-17-28652
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: