Provider Demographics
NPI:1093546434
Name:NUCKOLS, CLARA
Entity type:Individual
Prefix:
First Name:CLARA
Middle Name:
Last Name:NUCKOLS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2034 COTNER AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5664
Mailing Address - Country:US
Mailing Address - Phone:818-335-5200
Mailing Address - Fax:
Practice Address - Street 1:2034 COTNER AVE STE 200
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5664
Practice Address - Country:US
Practice Address - Phone:818-335-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-08
Last Update Date:2025-03-31
Deactivation Date:2024-08-14
Deactivation Code:
Reactivation Date:2025-03-31
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health