Provider Demographics
NPI:1013475219
Name:NICKLAS, STACEY L (PSYD, LMFT)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:L
Last Name:NICKLAS
Suffix:
Gender:F
Credentials:PSYD, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2999 OVERLAND AVE STE 217
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-4243
Mailing Address - Country:US
Mailing Address - Phone:310-271-8787
Mailing Address - Fax:
Practice Address - Street 1:2999 OVERLAND AVE STE 217
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-4243
Practice Address - Country:US
Practice Address - Phone:310-271-8787
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-06
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35768106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist