Provider Demographics
NPI:1467270710
Name:CHAVIS, NYCOLE CHRISTENA
Entity type:Individual
Prefix:
First Name:NYCOLE
Middle Name:CHRISTENA
Last Name:CHAVIS
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 1:900 N SOLDANO AVE
Mailing Address - Street 2:
Mailing Address - City:AZUSA
Mailing Address - State:CA
Mailing Address - Zip Code:91702-2443
Mailing Address - Country:US
Mailing Address - Phone:909-997-8052
Mailing Address - Fax:
Practice Address - Street 1:900 N SOLDANO AVE
Practice Address - Street 2:
Practice Address - City:AZUSA
Practice Address - State:CA
Practice Address - Zip Code:91702-2443
Practice Address - Country:US
Practice Address - Phone:909-997-8052
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-26
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1065521041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical