Provider Demographics
NPI:1346785805
Name:LAU, NICKIE
Entity Type:Individual
Prefix:
First Name:NICKIE
Middle Name:
Last Name:LAU
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 1:2909 OREGON CT
Mailing Address - Street 2:A1
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503-2645
Mailing Address - Country:US
Mailing Address - Phone:310-320-1333
Mailing Address - Fax:310-320-6555
Practice Address - Street 1:2909 OREGON CT
Practice Address - Street 2:A1
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-2645
Practice Address - Country:US
Practice Address - Phone:310-320-1333
Practice Address - Fax:310-320-6555
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-19
Last Update Date:2016-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-14-15151103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1-14-15151OtherBCBA LICENSE