Provider Demographics
NPI:1043844459
Name:HUSTON, NICKOLAS SLOAN
Entity type:Individual
Prefix:
First Name:NICKOLAS
Middle Name:SLOAN
Last Name:HUSTON
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 1:2371 W MAIN ST SPC 57
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-3614
Mailing Address - Country:US
Mailing Address - Phone:909-963-6044
Mailing Address - Fax:
Practice Address - Street 1:2371 W MAIN ST SPC 57
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-3614
Practice Address - Country:US
Practice Address - Phone:909-963-6044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-24
Last Update Date:2020-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF5775801103TH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TH0100XBehavioral Health & Social Service ProvidersPsychologistHealth Service