Provider Demographics
NPI:1114292182
Name:SMALL, NICHELLE L
Entity Type:Individual
Prefix:
First Name:NICHELLE
Middle Name:L
Last Name:SMALL
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 1:45 W OWENS AVE
Mailing Address - Street 2:132
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-6802
Mailing Address - Country:US
Mailing Address - Phone:702-399-5466
Mailing Address - Fax:
Practice Address - Street 1:21 W OWENS AVE
Practice Address - Street 2:134
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-6817
Practice Address - Country:US
Practice Address - Phone:702-399-5466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-09
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV880148782101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health