MEDICARE: ANDREW NICHOLS 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	103T00000X	Psychologist	8651960-2501	UT
2	103T00000X	Psychologist	019911	NY

General Provider Information

NPI Number	:	1902054091
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANDREW NICHOLS PH.D.

Provider Business Mailing Address
First Line	:	1389 CENTER DR
Second Line	:	STE 200
City	:	PARK CITY
State	:	UT
Zip	:	84098-7659
Country	:	US
Telephone Number	:	435-565-1816
Fax Number	:

Provider Business Practice Location Address
First Line	:	1389 CENTER DR
Second Line	:	STE 200
City	:	PARK CITY
State	:	UT
Zip	:	84098-7659
Country	:	US
Telephone Number	:	435-565-1816
Fax Number	:

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

Provider Enumeration Date	:	09/03/2008
Last Update Date	:	11/06/2014

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