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NPI Code Detail

MEDICARE: DR. SEAN MICHAEL NICKLEY PH.D.

MEDICARE: DR. SEAN MICHAEL NICKLEY 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
1103TC0700XClinical PsychologistPS020735PA

General Provider Information

NPI Number : 1730019282
Entity Type Code : Individual
Provider Name (Legal Business Name) : DR. SEAN MICHAEL NICKLEY PH.D.
Provider Business Mailing Address
First Line : 1251 N 29TH ST
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19121-4537
Country : US
Telephone Number :
Fax Number :
Provider Business Practice Location Address
First Line : 3900 WOODLAND AVE
Second Line :
City : PHILADELPHIA
State : PA
Zip : 19104-4551
Country : US
Telephone Number : 215-823-5800
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/19/2026
Last Update Date : 05/19/2026

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