Healthcare Provider Details

I. General information

NPI: 1194384883
Provider Name (Legal Business Name): BRANDON NICHTER PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 01/08/2026
Certification Date: 01/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48TH MDG/RAF LAKENHEATH
APO AE
09461
US

IV. Provider business mailing address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-8585
  • Fax:
Mailing address:
  • Phone: 858-552-8585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-005064
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: