Provider Demographics
NPI:1073702197
Name:VIENNA, NICOLE (PSYD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:VIENNA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:RADFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:464 E BONITA AVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:SAN DIMAS
Mailing Address - State:CA
Mailing Address - Zip Code:91773-3144
Mailing Address - Country:US
Mailing Address - Phone:626-709-3494
Mailing Address - Fax:
Practice Address - Street 1:464 E BONITA AVE
Practice Address - Street 2:SUITE 11
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-3144
Practice Address - Country:US
Practice Address - Phone:626-709-3494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-15
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACB261945Medicare PIN