Provider Demographics
NPI:1083047195
Name:NICHELLE, KIA
Entity Type:Individual
Prefix:
First Name:KIA
Middle Name:
Last Name:NICHELLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9825 MAGNOLIA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3565
Mailing Address - Country:US
Mailing Address - Phone:951-509-2499
Mailing Address - Fax:
Practice Address - Street 1:224 W GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-3740
Practice Address - Country:US
Practice Address - Phone:951-318-1351
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-12
Last Update Date:2020-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171W00000X
CAIMF84576106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171W00000XOther Service ProvidersContractor