Provider Demographics
NPI:1508232380
Name:NICLAS, DAVID (LMHC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:NICLAS
Suffix:
Gender:M
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1773 AVENIDA BONITA NW
Mailing Address - Street 2:
Mailing Address - City:LOS LUNAS
Mailing Address - State:NM
Mailing Address - Zip Code:87031-8369
Mailing Address - Country:US
Mailing Address - Phone:505-340-8324
Mailing Address - Fax:
Practice Address - Street 1:6611 GULTON CT NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4407
Practice Address - Country:US
Practice Address - Phone:505-296-3965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-17
Last Update Date:2015-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMT-0174521101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health