Healthcare Provider Details

I. General information

NPI: 1285001560
Provider Name (Legal Business Name): KELLY L NICHOLSON, PSYD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

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

III. Provider practice location address

19 SHELTER COVE LN
HILTON HEAD ISLAND SC
29928-3520
US

IV. Provider business mailing address

22 REDBUD WAY
BLUFFTON SC
29910-5605
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number1340
License Number StateSC

VIII. Authorized Official

Name: KELLY L NICHOLSON
Title or Position: PSYCHOLOGIST
Credential: PSYD
Phone: 843-226-6690