Provider Demographics
NPI:1447708292
Name:NICKIE, ARIEL NICKESHA (PSYD)
Entity type:Individual
Prefix:
First Name:ARIEL
Middle Name:NICKESHA
Last Name:NICKIE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CHURCH LN STE 101
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21208-3839
Mailing Address - Country:US
Mailing Address - Phone:410-343-9756
Mailing Address - Fax:
Practice Address - Street 1:104 CHURCH LN STE 101
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21208-3839
Practice Address - Country:US
Practice Address - Phone:410-343-9756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-21
Last Update Date:2020-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103199990001Medicaid
PAPO1831892OtherRAILROAD MEDICARE