Provider Demographics
NPI:1033528435
Name:NICHOLSON, BEN (LBA)
Entity Type:Individual
Prefix:MR
First Name:BEN
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:LBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:302 BARKER DR
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71203-6544
Mailing Address - Country:US
Mailing Address - Phone:318-243-6962
Mailing Address - Fax:
Practice Address - Street 1:302 BARKER DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71203-6544
Practice Address - Country:US
Practice Address - Phone:318-243-6962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2014-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAL-063103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst