Provider Demographics
NPI:1548451081
Name:NICHOLS, BRYAN K (PHD)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:K
Last Name:NICHOLS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9911 W PICO BLVD STE 1550
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90035-2712
Mailing Address - Country:US
Mailing Address - Phone:310-284-8060
Mailing Address - Fax:
Practice Address - Street 1:9911 W PICO BLVD STE 1550
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90035-2712
Practice Address - Country:US
Practice Address - Phone:310-284-8060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-08
Last Update Date:2007-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10255103T00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical