| Doctor Name: | MR. EARL M NICKERSON |
| NPI Number: | 1144359910 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | |
| License Number: | ALLSL916 |
| Business Practice Address: | 9 Doak Rd Belfast, ME - 04915 |
| Business Phone Number: | 2073383605 |
| Business Fax Number: | 2073380589 |
| Mailing Address: | 9 Doak Rd, BELFAST |
| State: | ME |
| Postal Code: | 04915 |
| Phone Number: | 2073383605 |
| Fax Number: | 2073380589 |
| NPI Enumeration Date: | 03/05/2007 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 320600000X |
| License Number: | ALLSL916 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | ME |
| Taxonomy Type: | Residential Treatment Facilities |
| Taxonomy Classification: | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A residential facility that provides habilitation services and other care and treatment to adults or children diagnosed with developmental disabilities and/or mental retardation and are not able to live independently. |