Provider Demographics
NPI:1194361410
Name:CARL, NICOLE LEA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEA
Last Name:CARL
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 1:60 E CLAY ST
Mailing Address - Street 2:
Mailing Address - City:COLUSA
Mailing Address - State:CA
Mailing Address - Zip Code:95932-2911
Mailing Address - Country:US
Mailing Address - Phone:707-541-8920
Mailing Address - Fax:
Practice Address - Street 1:590 RIO LINDO AVE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-1817
Practice Address - Country:US
Practice Address - Phone:530-345-3491
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-21
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1369851119101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)