Provider Demographics
NPI:1942656426
Name:NICKLE, MATTHEW
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:
Last Name:NICKLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 7000-15
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277
Mailing Address - Country:US
Mailing Address - Phone:424-225-1638
Mailing Address - Fax:
Practice Address - Street 1:1891 N GAFFEY ST
Practice Address - Street 2:230
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-1267
Practice Address - Country:US
Practice Address - Phone:310-831-1967
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA92602106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist