MEDICARE: BRYAN K. NICHOLS PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103T00000X	Psychologist	PSY10255	CA
2	103TC0700X	Clinical Psychologist	PSY10255	CA

General Provider Information

NPI Number	:	1548451081
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRYAN K. NICHOLS PH.D.

Provider Business Mailing Address
First Line	:	9911 W PICO BLVD STE 1550
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-2712
Country	:	US
Telephone Number	:	310-284-8060
Fax Number	:

Provider Business Practice Location Address
First Line	:	9911 W PICO BLVD STE 1550
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-2712
Country	:	US
Telephone Number	:	310-284-8060
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2007
Last Update Date	:	08/08/2007

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