Provider Demographics
NPI:1265253520
Name:NICHOLS, TRACY T (MA, LPT, LSPE)
Entity type:Individual
Prefix:
First Name:TRACY
Middle Name:T
Last Name:NICHOLS
Suffix:
Gender:U
Credentials:MA, LPT, LSPE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 CUMBERLAND ST E
Mailing Address - Street 2:
Mailing Address - City:COWAN
Mailing Address - State:TN
Mailing Address - Zip Code:37318-3265
Mailing Address - Country:US
Mailing Address - Phone:256-505-1735
Mailing Address - Fax:
Practice Address - Street 1:2011 GALLATIN ST SW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4510
Practice Address - Country:US
Practice Address - Phone:938-902-0494
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-21
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN11784103TC2200X
AL1185103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent