Basic Information
| Provider Information | |||||||||
| NPI: | 1649880493 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLS | ||||||||
| FirstName: | SHANE | ||||||||
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| Credential: | BCBA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2804 E 26TH ST STE 1 | ||||||||
| Address2: | |||||||||
| City: | SIOUX FALLS | ||||||||
| State: | SD | ||||||||
| PostalCode: | 571034019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6052712690 | ||||||||
| FaxNumber: | 6052713956 | ||||||||
| Practice Location | |||||||||
| Address1: | 1704 WESTLAND RD | ||||||||
| Address2: | |||||||||
| City: | CHEYENNE | ||||||||
| State: | WY | ||||||||
| PostalCode: | 820013322 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3072222400 | ||||||||
| FaxNumber: | 6052713956 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/06/2020 | ||||||||
| LastUpdateDate: | 02/09/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-20-42979 | WY | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.