MEDICARE: NICHOLAS NOLL PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103G00000X	Clinical Neuropsychologist	PYR0288	MO
2	103TC0700X	Clinical Psychologist	PYR0288	MO

General Provider Information

NPI Number	:	1407854292
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS NOLL PH.D.

Provider Business Mailing Address
First Line	:	1208 NE 97TH ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64155-2109
Country	:	US
Telephone Number	:	816-835-9882
Fax Number	:

Provider Business Practice Location Address
First Line	:	1208 NE 97TH ST
Second Line	:
City	:	KANSAS CITY
State	:	MO
Zip	:	64155-2109
Country	:	US
Telephone Number	:	816-835-9882
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/14/2005
Last Update Date	:	09/11/2025

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