Provider Demographics
NPI:1063930980
Name:NICHOLS, MILLISA JADE
Entity type:Individual
Prefix:
First Name:MILLISA
Middle Name:JADE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9829 BLUE LARKSPUR LN STE 2
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940-6535
Mailing Address - Country:US
Mailing Address - Phone:831-647-8490
Mailing Address - Fax:
Practice Address - Street 1:9829 BLUE LARKSPUR LN STE 2
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940-6535
Practice Address - Country:US
Practice Address - Phone:831-647-8490
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-30
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT131729106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist