Provider Demographics
NPI:1588100655
Name:NICHOLSON, KATHLEEN
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:
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 1:4215 MARY ELLEN AVE
Mailing Address - Street 2:APT 205
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604
Mailing Address - Country:US
Mailing Address - Phone:339-221-8867
Mailing Address - Fax:
Practice Address - Street 1:6426 W 5TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90048-4710
Practice Address - Country:US
Practice Address - Phone:323-825-7172
Practice Address - Fax:323-410-1044
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-13
Last Update Date:2022-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15-06-818106S00000X
390200000X
CA12041860103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program