Provider Demographics
NPI:1831494616
Name:JOHNSON, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JOHNSON
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 1:40 E MINARETS AVE
Mailing Address - Street 2:
Mailing Address - City:PINEDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93650-1239
Mailing Address - Country:US
Mailing Address - Phone:559-436-0482
Mailing Address - Fax:559-436-4650
Practice Address - Street 1:40 E MINARETS AVE
Practice Address - Street 2:
Practice Address - City:PINEDALE
Practice Address - State:CA
Practice Address - Zip Code:93650-1239
Practice Address - Country:US
Practice Address - Phone:559-436-0482
Practice Address - Fax:559-436-4650
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-25
Last Update Date:2014-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 66166106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist