Provider Demographics
NPI:1790794105
Name:MCCUISTION, NICOLE SUMMER (MFT)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:SUMMER
Last Name:MCCUISTION
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:131 W MIDWAY DR
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-6507
Mailing Address - Country:US
Mailing Address - Phone:714-717-3711
Mailing Address - Fax:
Practice Address - Street 1:131 W MIDWAY DR
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92805-6507
Practice Address - Country:US
Practice Address - Phone:714-517-7107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2010-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC42478106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist