Provider Demographics
NPI:1609036516
Name:NETTLES, CHRISTA NICHELL
Entity Type:Individual
Prefix:
First Name:CHRISTA
Middle Name:NICHELL
Last Name:NETTLES
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 1:320 N MADISON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3791
Mailing Address - Country:US
Mailing Address - Phone:323-644-2040
Mailing Address - Fax:
Practice Address - Street 1:320 N MADISON AVE STE B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90004-3791
Practice Address - Country:US
Practice Address - Phone:323-644-2040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-13
Last Update Date:2023-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X, 390200000X, 103T00000X
CA225C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No225C00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Counselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program