Provider Demographics
NPI:1679206833
Name:NICKOLL, LEIGH GROSSMAN
Entity type:Individual
Prefix:DR
First Name:LEIGH
Middle Name:GROSSMAN
Last Name:NICKOLL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:612 MORENO AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90049-4831
Mailing Address - Country:US
Mailing Address - Phone:310-488-6952
Mailing Address - Fax:
Practice Address - Street 1:612 MORENO AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90049-4831
Practice Address - Country:US
Practice Address - Phone:310-488-6952
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46659106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist