Provider Demographics
NPI:1285312371
Name:CHORNOMUD, NICHOLAS EDWARD
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:EDWARD
Last Name:CHORNOMUD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92703-2101
Mailing Address - Country:US
Mailing Address - Phone:714-972-1402
Mailing Address - Fax:
Practice Address - Street 1:1225 W 6TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92703-2101
Practice Address - Country:US
Practice Address - Phone:714-972-1402
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-07
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15629101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)