Provider Demographics
NPI:1831506617
Name:NICHOLSON-BRAIN, CRYSTAL (MA, BCBA)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:
Last Name:NICHOLSON-BRAIN
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17609 VENTURA BLVD STE 215
Mailing Address - Street 2:
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-5126
Mailing Address - Country:US
Mailing Address - Phone:818-501-8352
Mailing Address - Fax:
Practice Address - Street 1:100 S ANAHEIM BLVD STE 340
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-3877
Practice Address - Country:US
Practice Address - Phone:888-428-3223
Practice Address - Fax:323-866-1881
Is Sole Proprietor?:No
Enumeration Date:2014-07-14
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11314570103K00000X
103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst