Provider Demographics
NPI:1457626889
Name:REALLIFEDREAMS
Entity Type:Organization
Organization Name:REALLIFEDREAMS
Other - Org Name:LYNN L NICKENS, M.S.W., LCSW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICKENS
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:760-927-8896
Mailing Address - Street 1:1554 BARTON RD # 114
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-5457
Mailing Address - Country:US
Mailing Address - Phone:760-927-8896
Mailing Address - Fax:866-382-9020
Practice Address - Street 1:14240 SAINT ANDREWS DR
Practice Address - Street 2:SUITE 101
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4308
Practice Address - Country:US
Practice Address - Phone:760-927-8896
Practice Address - Fax:866-382-9020
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-19
Last Update Date:2012-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18158251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1114138252OtherNPI
CA1114138252OtherNPI