Basic Information
| Provider Information | |||||||||
| NPI: | 1003377300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKEL | ||||||||
| FirstName: | EMILY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BCABA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ERTZ | ||||||||
| OtherFirstName: | EMILY | ||||||||
| OtherMiddleName: | ANN | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 18726 S WESTERN AVE | ||||||||
| Address2: | |||||||||
| City: | GARDENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902483813 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3108560800 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Practice Location | |||||||||
| Address1: | 126 W OLIVE AVE | ||||||||
| Address2: | |||||||||
| City: | MONROVIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910163410 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262393060 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/28/2019 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-18-9199 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.