Provider Demographics
NPI:1295023075
Name:KNOWLTON, NICOLE MARIE (AMFT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:KNOWLTON
Suffix:
Gender:F
Credentials:AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 SHOOTING STAR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-3361
Mailing Address - Country:US
Mailing Address - Phone:949-293-7405
Mailing Address - Fax:
Practice Address - Street 1:4120 BIRCH ST STE 121
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2228
Practice Address - Country:US
Practice Address - Phone:714-540-9070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-14
Last Update Date:2022-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122657106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist