Provider Demographics
NPI:1689239600
Name:MCINTIRE, NICHOLE MONIQUE
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:MONIQUE
Last Name:MCINTIRE
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 1:1621 W 226TH ST APT 4
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-6627
Mailing Address - Country:US
Mailing Address - Phone:424-407-5340
Mailing Address - Fax:
Practice Address - Street 1:235 W 9TH ST
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3711
Practice Address - Country:US
Practice Address - Phone:310-521-9209
Practice Address - Fax:310-521-9241
Is Sole Proprietor?:No
Enumeration Date:2019-05-06
Last Update Date:2019-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)