Provider Demographics
NPI:1962853382
Name:NICOLAS, CHRISTELLE
Entity Type:Individual
Prefix:
First Name:CHRISTELLE
Middle Name:
Last Name:NICOLAS
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 1:8885 RIO SAN DIEGO DRIVE
Mailing Address - Street 2:#340
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108
Mailing Address - Country:US
Mailing Address - Phone:786-556-9694
Mailing Address - Fax:
Practice Address - Street 1:10185 PARK MEADOWS DR.
Practice Address - Street 2:
Practice Address - City:LONE TREE
Practice Address - State:CO
Practice Address - Zip Code:80124
Practice Address - Country:US
Practice Address - Phone:786-556-9694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-27
Last Update Date:2021-04-07
Deactivation Date:2021-02-25
Deactivation Code:
Reactivation Date:2021-03-24
Provider Licenses
StateLicense IDTaxonomies
103K00000X, 106E00000X
1-20-46338103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst