Provider Demographics
NPI:1487056198
Name:ANDERSON, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:ANDERSON
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 1:360 E 1ST ST # 415
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92780-3211
Mailing Address - Country:US
Mailing Address - Phone:714-342-7612
Mailing Address - Fax:
Practice Address - Street 1:14751 PLAZA DR STE E
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2773
Practice Address - Country:US
Practice Address - Phone:714-342-7612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-24
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA99487106H00000X
CA79357101YM0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NAOtherNA