Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YM0800X | Mental Health Counselor | ||
N | 225XM0800X | Mental Health |
NPI | 1013441211 |
---|---|
Provider Name | Nichelle Space |
First Address | Los Angeles, CA 90001-3409 |
Second Address | Los Angeles, CA 90001-3409 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 13/04/2017 |
Last Update Date | 10/02/2020 |