| Doctor Name: | THERON ROBERT NICHOLSON |
| NPI Number: | 1124498423 |
| Entity Type Code: | Individual (1) |
| Gender: | M |
| Credentials: | LMHC |
| License Number: | 0175751 |
| Business Practice Address: | 3465 Mcnutt Rd Sunland Park, NM - 880639056 |
| Business Phone Number: | 5759151338 |
| Business Fax Number: | 5759151819 |
| Mailing Address: | 5305 Mcnutt Rd, SANTA TERESA |
| State: | NM |
| Postal Code: | 880088937 |
| Phone Number: | 5758825100 |
| Fax Number: | 5758821151 |
| NPI Enumeration Date: | 09/29/2015 |
| NPI Last Update Date: | 01/19/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YM0800X |
| License Number: | 0175751 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NM |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Mental Health |
| Taxonomy Definition: | |