Doctor Name: | DR. KELLY L NICHOLSON |
NPI Number: | 1043424807 |
Entity Type Code: | Individual (1) |
Gender: | F |
Credentials: | PSY.D. |
License Number: | 3154 |
Business Practice Address: | 1605 Moonstone Ln Castle Rock, CO - 801087809 |
Business Phone Number: | 7205886772 |
Business Fax Number: | |
Mailing Address: | 22 Redbud Way, BLUFFTON |
State: | SC |
Postal Code: | 299105605 |
Phone Number: | 8432266690 |
Fax Number: | |
NPI Enumeration Date: | 05/10/2007 |
NPI Last Update Date: | 08/21/2015 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 103TC0700X |
License Number: | 3154 |
Healthcare Provider Taxonomy: (Secondary) | N |
State: | CO |
Taxonomy Type: | Behavioral Health & Social Service Providers |
Taxonomy Classification: | Psychologist |
Taxonomy Specialization: | Clinical |
Taxonomy Definition: |