Provider Demographics
NPI:1659039758
Name:GARCIA, NICOLETTE LANITA
Entity Type:Individual
Prefix:
First Name:NICOLETTE
Middle Name:LANITA
Last Name:GARCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICOLETTE
Other - Middle Name:L
Other - Last Name:PATRON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:541 S HAM LN STE A&B
Mailing Address - Street 2:
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95242-3530
Mailing Address - Country:US
Mailing Address - Phone:209-553-0798
Mailing Address - Fax:
Practice Address - Street 1:541 S HAM LN STE A&B
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95242-3530
Practice Address - Country:US
Practice Address - Phone:209-553-0798
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)