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NPI Code Detail

MEDICARE: DR. PETER MICHAEL NICHOLAS LCSW

MEDICARE: DR. PETER MICHAEL NICHOLAS LCSW
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
11041C0700XClinical Social Worker1192563501UT

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1289948OTHERUTDESERET MUTUAL
2107001279101OTHERUTINTERMOUNTAIN HEALTH CARE
3942938348NI1OTHERUTEDUCATOR'S MUTUAL

General Provider Information

NPI Number : 1588643852
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. PETER MICHAEL NICHOLAS LCSW
Provider Business Mailing Address
First Line : 780 GUARDSMAN WAY
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84108-1374
Country : US
Telephone Number : 801-581-0194
Fax Number : 801-581-0193
Provider Business Practice Location Address
First Line : 780 GUARDSMAN WAY
Second Line :
City : SALT LAKE CITY
State : UT
Zip : 84108-1374
Country : US
Telephone Number : 801-581-0194
Fax Number : 801-581-0193
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 01/13/2006
Last Update Date : 03/17/2008

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