Provider Demographics
NPI:1609091859
Name:NIES, DOUGLAS CHRISTIAN (PHD)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:CHRISTIAN
Last Name:NIES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1530 E CHEVY CHASE DR
Mailing Address - Street 2:SUITE 209
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91206-4163
Mailing Address - Country:US
Mailing Address - Phone:818-240-7454
Mailing Address - Fax:
Practice Address - Street 1:1530 E CHEVY CHASE DR
Practice Address - Street 2:SUITE 209
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91206-4163
Practice Address - Country:US
Practice Address - Phone:818-240-7454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-14
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 8297103G00000X, 103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP8297Medicare ID - Type UnspecifiedPROVIDER NUMBER