Provider Demographics
NPI:1366647257
Name:GERDES, NANCY
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:
Last Name:GERDES
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 1:25910 ACERO STE 160
Mailing Address - Street 2:
Mailing Address - City:MISSION VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92691-2777
Mailing Address - Country:US
Mailing Address - Phone:909-335-7067
Mailing Address - Fax:909-792-2045
Practice Address - Street 1:1323 W COLTON AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4554
Practice Address - Country:US
Practice Address - Phone:909-792-0747
Practice Address - Fax:909-792-0033
Is Sole Proprietor?:No
Enumeration Date:2007-06-19
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4529OtherSIMON STAFF NUMBER