Basic Information
| Provider Information | |||||||||
| NPI: | 1124498423 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICHOLSON | ||||||||
| FirstName: | THERON | ||||||||
| MiddleName: | ROBERT | ||||||||
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| Credential: | LMHC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5305 MCNUTT RD | ||||||||
| Address2: | |||||||||
| City: | SANTA TERESA | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880088937 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5758825100 | ||||||||
| FaxNumber: | 5758821151 | ||||||||
| Practice Location | |||||||||
| Address1: | 3465 MCNUTT RD | ||||||||
| Address2: | |||||||||
| City: | SUNLAND PARK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880639056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5759151338 | ||||||||
| FaxNumber: | 5759151819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2015 | ||||||||
| LastUpdateDate: | 01/19/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 0175751 | NM | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 64153274 | 05 | NM | MEDICAID |