Provider Demographics
NPI:1235645557
Name:NICHOLAS, LORIE LYNN
Entity Type:Individual
Prefix:
First Name:LORIE
Middle Name:LYNN
Last Name:NICHOLAS
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 1:21101 DALE EVANS PKWY
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-9356
Mailing Address - Country:US
Mailing Address - Phone:760-961-6631
Mailing Address - Fax:
Practice Address - Street 1:21101 DALE EVANS PKWY
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-9356
Practice Address - Country:US
Practice Address - Phone:760-961-6631
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-22
Last Update Date:2024-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA054870923101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)