Provider Demographics
NPI:1134698954
Name:NICKLAS, KYLEY
Entity Type:Individual
Prefix:
First Name:KYLEY
Middle Name:
Last Name:NICKLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KYLEY
Other - Middle Name:
Other - Last Name:ROUSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4050 W METROPOLITAN DR STE 100
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-3502
Mailing Address - Country:US
Mailing Address - Phone:949-401-3931
Mailing Address - Fax:888-403-6922
Practice Address - Street 1:4050 W METROPOLITAN DR STE 100
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3502
Practice Address - Country:US
Practice Address - Phone:949-401-3931
Practice Address - Fax:888-403-6922
Is Sole Proprietor?:No
Enumeration Date:2018-11-21
Last Update Date:2023-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-19-38548103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst