Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 101YA0400X | Addiction Counselor (Substance Use Disorder) | R1370771119 | CA |
NPI | 1003431495 |
---|---|
Provider Name | Travis George Nichols |
First Address | Sacramento, CA 95816-7109 |
Second Address | Sacramento, CA 95816-7109 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/06/2020 |
Last Update Date | 10/06/2020 |