Healthcare Provider Details

I. General information

NPI: 1508289596
Provider Name (Legal Business Name): NICOLAS HARVEY MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2014
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E CALIFORNIA BLVD
PASADENA CA
91125-0002
US

IV. Provider business mailing address

1200 E CALIFORNIA BLVD
PASADENA CA
91125-0002
US

V. Phone/Fax

Practice location:
  • Phone: 619-249-2054
  • Fax:
Mailing address:
  • Phone: 619-249-2054
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number060802208
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: