Provider Demographics
NPI:1790219715
Name:SORACE, NICOLE LEANNE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEANNE
Last Name:SORACE
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 1:3478 BUSKIRK AVE STE 260
Mailing Address - Street 2:
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-4358
Mailing Address - Country:US
Mailing Address - Phone:925-943-1794
Mailing Address - Fax:925-943-6091
Practice Address - Street 1:3478 BUSKIRK AVE STE 260
Practice Address - Street 2:
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-4358
Practice Address - Country:US
Practice Address - Phone:925-943-1794
Practice Address - Fax:925-943-6091
Is Sole Proprietor?:No
Enumeration Date:2017-04-17
Last Update Date:2023-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X, 390200000X
CA130359106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program