Healthcare Provider Details

I. General information

NPI: 1588977003
Provider Name (Legal Business Name): NICHOLAS T STAUTH M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2010
Last Update Date: 07/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16055 VENTURA BLVD STE 810
ENCINO CA
91436-2610
US

IV. Provider business mailing address

PO BOX 570139
TARZANA CA
91357-0139
US

V. Phone/Fax

Practice location:
  • Phone: 818-430-1406
  • Fax:
Mailing address:
  • Phone: 818-430-1406
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC80610
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: