MEDICARE: MARTI LEEANN NICHOLS LBHP

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	103TA0400X	Addiction (Substance Use Disorder) Psychologist		OK
2	103TR0400X	Rehabilitation Psychologist
3	101YM0800X	Mental Health Counselor	1274	OK

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1538495692
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARTI LEEANN NICHOLS LBHP

Provider Business Mailing Address
First Line	:	56577 COUNTY ROAD 660
Second Line	:
City	:	COLCORD
State	:	OK
Zip	:	74338-2520
Country	:	US
Telephone Number	:	918-864-0353
Fax Number	:

Provider Business Practice Location Address
First Line	:	56577 COUNTY ROAD 660
Second Line	:
City	:	COLCORD
State	:	OK
Zip	:	74338-2520
Country	:	US
Telephone Number	:	918-864-0353
Fax Number	:

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

Provider Enumeration Date	:	10/26/2009
Last Update Date	:	11/11/2025

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