Provider Demographics
NPI:1164735551
Name:LIGHTMAN, NICOLE SALLY (PHD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SALLY
Last Name:LIGHTMAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26224
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92799-6224
Mailing Address - Country:US
Mailing Address - Phone:520-400-8171
Mailing Address - Fax:
Practice Address - Street 1:4700 VON KARMAN AVE STE 102
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660
Practice Address - Country:US
Practice Address - Phone:949-743-1457
Practice Address - Fax:949-629-2500
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-14
Last Update Date:2018-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY28608103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent