Provider Demographics
NPI:1083919104
Name:NICHOLSON, KRISTAL SHELLEY (MA)
Entity Type:Individual
Prefix:
First Name:KRISTAL
Middle Name:SHELLEY
Last Name:NICHOLSON
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5116 E 27TH PL
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74114-4912
Mailing Address - Country:US
Mailing Address - Phone:918-671-3392
Mailing Address - Fax:413-431-1359
Practice Address - Street 1:5840 S MEMORIAL DR
Practice Address - Street 2:SUITE NO. 3003
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74145-9023
Practice Address - Country:US
Practice Address - Phone:918-671-3392
Practice Address - Fax:413-431-1359
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-20
Last Update Date:2011-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1768101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor