Provider Demographics
NPI:1528544509
Name:BLACK, NICOLAS ANDREW
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:ANDREW
Last Name:BLACK
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 1:205 DAISY AVE APT 2
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240-1156
Mailing Address - Country:US
Mailing Address - Phone:209-581-2031
Mailing Address - Fax:
Practice Address - Street 1:87 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5731
Practice Address - Country:US
Practice Address - Phone:877-828-8476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-12
Last Update Date:2018-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician