Provider Demographics
NPI:1891891115
Name:NICOLAS, BERNARD (MA, LMFT)
Entity Type:Individual
Prefix:MR
First Name:BERNARD
Middle Name:
Last Name:NICOLAS
Suffix:
Gender:M
Credentials:MA, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1379 W PARK WESTERN DR
Mailing Address - Street 2:#262
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90732-2300
Mailing Address - Country:US
Mailing Address - Phone:424-264-9058
Mailing Address - Fax:
Practice Address - Street 1:23505 CRENSHAW BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5221
Practice Address - Country:US
Practice Address - Phone:424-264-9058
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC43591106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist