Provider Demographics
NPI:1730542382
Name:CLELLAND, NICOLE ANN
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:ANN
Last Name:CLELLAND
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:ANN
Other - Last Name:COSTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:23832 ROCKFIELD BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-2870
Mailing Address - Country:US
Mailing Address - Phone:949-415-4489
Mailing Address - Fax:
Practice Address - Street 1:23832 ROCKFIELD BLVD STE 120
Practice Address - Street 2:
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-2870
Practice Address - Country:US
Practice Address - Phone:949-415-4489
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-31
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101251101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health