Basic Information
| Provider Information | |||||||||
| NPI: | 1942431721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NILSEN | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | LESLIE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2940 N VERDUGO RD UNIT 407 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912082129 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9492358449 | ||||||||
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| Practice Location | |||||||||
| Address1: | 210 S DE LACEY AVE | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911052048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7146809000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/28/2009 | ||||||||
| LastUpdateDate: | 06/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 54231 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.