=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831501295
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. LARRY NICHOLAS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/20/2014
-----------------------------------------------------
Last Update Date | 05/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2428 K ST
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95816-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-448-3822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2428 K ST
-----------------------------------------------------
City | SACRAMENTO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95816-5002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY8294
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------