Provider Demographics
NPI:1710725106
Name:NICHOLS, CECILY REDMOND
Entity type:Individual
Prefix:
First Name:CECILY
Middle Name:REDMOND
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:871 S MONUMENT PARK CIR
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84108-1442
Mailing Address - Country:US
Mailing Address - Phone:385-231-8648
Mailing Address - Fax:
Practice Address - Street 1:473 K ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-3625
Practice Address - Country:US
Practice Address - Phone:385-231-8648
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-18
Last Update Date:2024-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT13980424-4701225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist