Basic Information
| Provider Information | |||||||||
| NPI: | 1376168252 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NYQUIST | ||||||||
| FirstName: | ALEX | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 BURNET AVE | ||||||||
| Address2: | ML 5021 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364225 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3333 BURNET AVE ML 3015 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5136364336 | ||||||||
| FaxNumber: | 5136367756 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/16/2020 | ||||||||
| LastUpdateDate: | 01/06/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | P.08225 | OH | N | Behavioral Health & Social Service Providers | Psychologist | Clinical | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 103TC2200X | P.08225 | OH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical Child & Adolescent |
No ID Information.