Provider Demographics
NPI:1669018768
Name:TRESCH, NICOLE MARIE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:TRESCH
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 1:3953 CHATSWORTH CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-1565
Mailing Address - Country:US
Mailing Address - Phone:239-410-1046
Mailing Address - Fax:
Practice Address - Street 1:1811 GRAND CANAL BLVD STE 2
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-8107
Practice Address - Country:US
Practice Address - Phone:877-418-2978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-23
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician