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General NPI Number Information
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NPI Number | 1790019511
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Entity Type | Individual
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Provider Name | RILEY NICKOLS
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Gender | Male
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Dates
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Enumeration Date | 09/25/2009
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Last Update Date | 04/21/2020
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Provider Practice Location Address
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Address Line | 231 W LOCKWOOD AVE SUITE 201
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City | SAINT LOUIS
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State | MO
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Zip | 63119-2951
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Country | US
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Telephone | 314-968-1900
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Fax |
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Provider Business Mailing Address
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Address Line | 16 N GORE AVE STE 204
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City | SAINT LOUIS
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State | MO
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Zip | 63119-2315
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Country | US
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Telephone | 513-505-2160
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 2013032493
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License Number State | MO
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