Provider Demographics
NPI:1609136571
Name:WITKIN, NICOLE DIZON (PSYD)
Entity Type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:DIZON
Last Name:WITKIN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:DIZON
Other - Last Name:PANGANIBAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:317 14TH ST STE E
Mailing Address - Street 2:
Mailing Address - City:DEL MAR
Mailing Address - State:CA
Mailing Address - Zip Code:92014-2554
Mailing Address - Country:US
Mailing Address - Phone:858-876-7728
Mailing Address - Fax:
Practice Address - Street 1:317 14TH ST SUITE E
Practice Address - Street 2:
Practice Address - City:DEL-MAR
Practice Address - State:CA
Practice Address - Zip Code:92014
Practice Address - Country:US
Practice Address - Phone:858-876-7728
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-24
Last Update Date:2020-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X, 390200000X
CA32204103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program