Provider Demographics
NPI:1053929265
Name:NICHOLS, CHELSEA DIANE
Entity type:Individual
Prefix:MRS
First Name:CHELSEA
Middle Name:DIANE
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CHELSEA
Other - Middle Name:DIANE
Other - Last Name:CANTRALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:12115 LA VISTA GRANDE DR NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87111-6708
Mailing Address - Country:US
Mailing Address - Phone:505-908-1354
Mailing Address - Fax:
Practice Address - Street 1:1025 HERMOSA DR SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108-4312
Practice Address - Country:US
Practice Address - Phone:505-237-0061
Practice Address - Fax:505-237-0068
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2020-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-115051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical