Provider Demographics
NPI:1093838427
Name:HUERTA, NICOLAS
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:HUERTA
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 1:3501 SPRUCE AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150-2302
Mailing Address - Country:US
Mailing Address - Phone:530-542-0740
Mailing Address - Fax:530-542-0397
Practice Address - Street 1:3501 SPRUCE AVE STE B
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150-2302
Practice Address - Country:US
Practice Address - Phone:530-542-0740
Practice Address - Fax:530-542-0397
Is Sole Proprietor?:No
Enumeration Date:2007-04-09
Last Update Date:2013-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health