Healthcare Provider Details

I. General information

NPI: 1679609960
Provider Name (Legal Business Name): BRENDA LARUE NICHOLS MFT INTERN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 02/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4025 W 226TH ST
TORRANCE CA
90505-2340
US

IV. Provider business mailing address

13107 S SAINT ANDREWS PL
GARDENA CA
90249-1831
US

V. Phone/Fax

Practice location:
  • Phone: 310-373-4556
  • Fax: 310-373-4096
Mailing address:
  • Phone: 310-400-3009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number58785
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: