Healthcare Provider Details

I. General information

NPI: 1043424807
Provider Name (Legal Business Name): KELLY L NICHOLSON PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/10/2007
Last Update Date: 08/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1605 MOONSTONE LN
CASTLE ROCK CO
80108-7809
US

IV. Provider business mailing address

22 REDBUD WAY
BLUFFTON SC
29910-5605
US

V. Phone/Fax

Practice location:
  • Phone: 720-588-6772
  • Fax:
Mailing address:
  • Phone: 843-226-6690
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number3154
License Number StateCO
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1340
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: