Provider Demographics
NPI:1700165602
Name:NICOLOSI, JOSEPH JOHN JR (PHD)
Entity type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:JOHN
Last Name:NICOLOSI
Suffix:JR
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 1:17835 VENTURA BLVD
Mailing Address - Street 2:STE # 207
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316
Mailing Address - Country:US
Mailing Address - Phone:818-609-0147
Mailing Address - Fax:
Practice Address - Street 1:17835 VENTURA BLVD
Practice Address - Street 2:STE # 207
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316
Practice Address - Country:US
Practice Address - Phone:818-609-0147
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-09
Last Update Date:2018-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25555103TC0700X
CAPSB36547103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical