Provider Demographics
NPI:1588977003
Name:STAUTH, NICHOLAS T (MS)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:T
Last Name:STAUTH
Suffix:
Gender:M
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 570139
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91357-0139
Mailing Address - Country:US
Mailing Address - Phone:818-430-1406
Mailing Address - Fax:
Practice Address - Street 1:16055 VENTURA BLVD STE 810
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2610
Practice Address - Country:US
Practice Address - Phone:818-430-1406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-26
Last Update Date:2015-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CAMFC80610106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner