MEDICARE: DR. NICOLE LEVAILLANT PSY.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	103TC0700X	Clinical Psychologist	24045	CA

General Provider Information

NPI Number	:	1720383185
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE LEVAILLANT PSY.D

Provider Business Mailing Address
First Line	:	PO BOX 9
Second Line	:
City	:	SAN CARLOS
State	:	CA
Zip	:	94070-0009
Country	:	US
Telephone Number	:	408-636-6036
Fax Number	:

Provider Business Practice Location Address
First Line	:	BUILDING 786 D STREET
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99505
Country	:	US
Telephone Number	:	408-636-6036
Fax Number	:

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

Provider Enumeration Date	:	01/17/2011
Last Update Date	:	10/22/2019

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