Provider Demographics
NPI:1053771105
Name:ANDERS, NICOLE (PSYD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ANDERS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6900 N PECOS RD
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89086-4400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6787 W TROPICANA AVE STE 241
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-4759
Practice Address - Country:US
Practice Address - Phone:833-624-5400
Practice Address - Fax:866-497-0441
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA28048103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100557970Medicaid
CA1053771105Medicaid