Provider Demographics
NPI:1114442241
Name:BOULEVARD THERAPY
Entity Type:Organization
Organization Name:BOULEVARD THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL PSYCHOLOGIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WALKER
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:818-512-8164
Mailing Address - Street 1:12456 VENTURA BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2484
Mailing Address - Country:US
Mailing Address - Phone:818-512-8164
Mailing Address - Fax:
Practice Address - Street 1:12456 VENTURA BLVD STE 1
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2484
Practice Address - Country:US
Practice Address - Phone:818-512-8164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16783103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty