Provider Demographics
NPI:1043424807
Name:NICHOLSON, KELLY L (PSYD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:L
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22 REDBUD WAY
Mailing Address - Street 2:
Mailing Address - City:BLUFFTON
Mailing Address - State:SC
Mailing Address - Zip Code:29910-5605
Mailing Address - Country:US
Mailing Address - Phone:843-226-6690
Mailing Address - Fax:
Practice Address - Street 1:1605 MOONSTONE LN
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80108-7809
Practice Address - Country:US
Practice Address - Phone:720-588-6772
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-10
Last Update Date:2015-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO3154103TC0700X
SC1340103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical