Provider Demographics
NPI:1942431721
Name:NILSEN, NICOLE LESLIE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LESLIE
Last Name:NILSEN
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 1:2940 N VERDUGO RD UNIT 407
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91208-2129
Mailing Address - Country:US
Mailing Address - Phone:949-235-8449
Mailing Address - Fax:
Practice Address - Street 1:210 S DE LACEY AVE
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2048
Practice Address - Country:US
Practice Address - Phone:714-680-9000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54231106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist