Provider Demographics
NPI:1801211404
Name:NICOLE MEVORAK
Entity Type:Organization
Organization Name:NICOLE MEVORAK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSED MARRIAGE FAMILY THERAPIST
Authorized Official - Prefix:MRS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:DAVINA
Authorized Official - Last Name:MEVORAK
Authorized Official - Suffix:
Authorized Official - Credentials:MS
Authorized Official - Phone:818-400-7311
Mailing Address - Street 1:11712 MOORPARK ST
Mailing Address - Street 2:SUITE 114
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-2154
Mailing Address - Country:US
Mailing Address - Phone:818-400-7311
Mailing Address - Fax:
Practice Address - Street 1:11712 MOORPARK ST
Practice Address - Street 2:SUITE 114
Practice Address - City:STUDIO CITY
Practice Address - State:CA
Practice Address - Zip Code:91604-2154
Practice Address - Country:US
Practice Address - Phone:818-400-7311
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-02-19
Last Update Date:2014-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52895106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty