Provider Demographics
NPI:1437883303
Name:BADIS, NICHOLAS W
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:W
Last Name:BADIS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 VISTA MONTANA WAY
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-4549
Mailing Address - Country:US
Mailing Address - Phone:909-219-0274
Mailing Address - Fax:
Practice Address - Street 1:4405 W RIVERSIDE DR STE 209
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4050
Practice Address - Country:US
Practice Address - Phone:818-588-7141
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-14
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT129050106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty