Provider Demographics
NPI:1770079816
Name:NICHOLSON, CLINTON E (MA, LPC)
Entity type:Individual
Prefix:MR
First Name:CLINTON
Middle Name:E
Last Name:NICHOLSON
Suffix:
Gender:M
Credentials:MA, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:1840 WOODMOOR DR STE 102
Mailing Address - Street 2:
Mailing Address - City:MONUMENT
Mailing Address - State:CO
Mailing Address - Zip Code:80132-9083
Mailing Address - Country:US
Mailing Address - Phone:719-622-6522
Mailing Address - Fax:719-622-6520
Practice Address - Street 1:1259 LAKE PLAZA DR STE 200
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3516
Practice Address - Country:US
Practice Address - Phone:719-622-6522
Practice Address - Fax:719-622-6520
Is Sole Proprietor?:No
Enumeration Date:2018-07-02
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0001759101YA0400X
CO0016143101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)