Provider Demographics
NPI:1720383185
Name:LEVAILLANT, NICOLE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:LEVAILLANT
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-0009
Mailing Address - Country:US
Mailing Address - Phone:408-636-6036
Mailing Address - Fax:
Practice Address - Street 1:BUILDING 786 D STREET
Practice Address - Street 2:
Practice Address - City:ANCHORAGE
Practice Address - State:AK
Practice Address - Zip Code:99505
Practice Address - Country:US
Practice Address - Phone:408-636-6036
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-17
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA24045103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical