Provider Demographics
NPI:1568855773
Name:NIKIFORUK, CARLY
Entity Type:Individual
Prefix:
First Name:CARLY
Middle Name:
Last Name:NIKIFORUK
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 1:24625 ARCH ST
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-1111
Mailing Address - Country:US
Mailing Address - Phone:661-288-2644
Mailing Address - Fax:661-288-2669
Practice Address - Street 1:24625 ARCH ST.
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321
Practice Address - Country:US
Practice Address - Phone:661-288-2644
Practice Address - Fax:661-288-2669
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2015-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor