MEDICARE: KELLY L NICHOLSON, PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	1340	SC

General Provider Information

NPI Number	:	1285001560
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KELLY L NICHOLSON, PSYD

Provider Business Mailing Address
First Line	:	22 REDBUD WAY
Second Line	:
City	:	BLUFFTON
State	:	SC
Zip	:	29910-5605
Country	:	US
Telephone Number	:	843-226-6690
Fax Number	:

Provider Business Practice Location Address
First Line	:	19 SHELTER COVE LN
Second Line	:
City	:	HILTON HEAD ISLAND
State	:	SC
Zip	:	29928-3520
Country	:	US
Telephone Number	:	843-226-6690
Fax Number	:

Authorized Official
Title or Position	:	PSYCHOLOGIST
Name	:	KELLY L NICHOLSON
Credential	:	PSYD
Telephone Number	:	843-226-6690

Provider Enumeration Date	:	08/21/2015
Last Update Date	:	08/21/2015

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