Provider Demographics
NPI:1124911722
Name:NICKELL, NOAH MITCHELL
Entity type:Individual
Prefix:
First Name:NOAH
Middle Name:MITCHELL
Last Name:NICKELL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 MISTY ELM CT
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93455-3304
Mailing Address - Country:US
Mailing Address - Phone:805-668-9976
Mailing Address - Fax:
Practice Address - Street 1:1111 E OCEAN AVE STE 4A
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2500
Practice Address - Country:US
Practice Address - Phone:805-568-7895
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-02
Last Update Date:2025-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty