Provider Demographics
NPI:1861187239
Name:VETTEL, NICOLE DAE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DAE
Last Name:VETTEL
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 1:3553 ATLANTIC AVE # 670
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-5606
Mailing Address - Country:US
Mailing Address - Phone:818-419-2015
Mailing Address - Fax:
Practice Address - Street 1:2698 DAWSON AVE STE G
Practice Address - Street 2:
Practice Address - City:SIGNAL HILL
Practice Address - State:CA
Practice Address - Zip Code:90755-2066
Practice Address - Country:US
Practice Address - Phone:562-452-4810
Practice Address - Fax:562-452-4811
Is Sole Proprietor?:No
Enumeration Date:2023-04-10
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA38329106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist