Provider Demographics
NPI:1063981132
Name:NICHOLSON, TAYLOR MARIE
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:MARIE
Last Name:NICHOLSON
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 1:8755 AERO DR STE 230
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92123-1750
Mailing Address - Country:US
Mailing Address - Phone:858-256-2180
Mailing Address - Fax:000-000-0000
Practice Address - Street 1:8755 AERO DR STE 230
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1750
Practice Address - Country:US
Practice Address - Phone:858-256-2180
Practice Address - Fax:000-000-0000
Is Sole Proprietor?:No
Enumeration Date:2018-11-19
Last Update Date:2021-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY3942658106S00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician