Provider Demographics
NPI:1053139808
Name:GASTIL, NICKOLAUS H (PSYCH)
Entity type:Individual
Prefix:
First Name:NICKOLAUS
Middle Name:H
Last Name:GASTIL
Suffix:
Gender:M
Credentials:PSYCH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 S ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2353
Mailing Address - Country:US
Mailing Address - Phone:812-314-3400
Mailing Address - Fax:812-337-2438
Practice Address - Street 1:645 S ROGERS ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2353
Practice Address - Country:US
Practice Address - Phone:812-314-3400
Practice Address - Fax:812-337-2438
Is Sole Proprietor?:No
Enumeration Date:2024-10-01
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN20043859A103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist