Healthcare Provider Details

I. General information

NPI: 1154875789
Provider Name (Legal Business Name): KAITLYN NICHOLS M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3443 W SHAW AVE
FRESNO CA
93711-3249
US

IV. Provider business mailing address

3443 W SHAW AVE
FRESNO CA
93711-3249
US

V. Phone/Fax

Practice location:
  • Phone: 559-271-1186
  • Fax:
Mailing address:
  • Phone: 559-271-1186
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number94022754
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number30721
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: