Provider Demographics
NPI:1174261051
Name:DR. NICOLE CHAVEZ PSYCHOLOGICAL SERVICES P.C.
Entity Type:Organization
Organization Name:DR. NICOLE CHAVEZ PSYCHOLOGICAL SERVICES P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHAVEZ
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:949-280-4685
Mailing Address - Street 1:1555 MESA VERDE DR E APT 40K
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-5246
Mailing Address - Country:US
Mailing Address - Phone:949-280-4685
Mailing Address - Fax:
Practice Address - Street 1:427 E 17TH ST # STF-1112
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92627-3201
Practice Address - Country:US
Practice Address - Phone:949-280-4685
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-21
Last Update Date:2022-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & AdolescentGroup - Single Specialty