Provider Demographics
NPI:1295186294
Name:NICHOLSON, BORNELL (PHD)
Entity Type:Individual
Prefix:DR
First Name:BORNELL
Middle Name:
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1818 W FRANCIS AVE # 299
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99205-6834
Mailing Address - Country:US
Mailing Address - Phone:509-596-1435
Mailing Address - Fax:
Practice Address - Street 1:1818 W FRANCIS AVE # 299
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99205-6834
Practice Address - Country:US
Practice Address - Phone:509-596-1435
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-30
Last Update Date:2024-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF61468637106H00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor