Provider Demographics
NPI:1376398693
Name:NGO, NICOLE (EDS, PPS, LEP)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:NGO
Suffix:
Gender:F
Credentials:EDS, PPS, LEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3130 E 2ND ST APT 10
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-7316
Mailing Address - Country:US
Mailing Address - Phone:714-487-9808
Mailing Address - Fax:
Practice Address - Street 1:3130 E 2ND ST APT 10
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90803-7316
Practice Address - Country:US
Practice Address - Phone:714-487-9808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-19
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4144103TB0200X, 103TM1800X, 103TS0200X, 103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TB0200XBehavioral Health & Social Service ProvidersPsychologistCognitive & Behavioral
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities
No103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool