Provider Demographics
NPI:1760586051
Name:NICELY, PAMELA (PHD)
Entity Type:Individual
Prefix:DR
First Name:PAMELA
Middle Name:
Last Name:NICELY
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4419 COLDWATER CANYON AVE STE J
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-1479
Mailing Address - Country:US
Mailing Address - Phone:818-795-3676
Mailing Address - Fax:856-441-1429
Practice Address - Street 1:4419 COLDWATER CANYON AVE STE J
Practice Address - Street 2:
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-1479
Practice Address - Country:US
Practice Address - Phone:818-795-3676
Practice Address - Fax:856-441-1429
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-08
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY16450103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ66500Medicare UPIN