Provider Demographics
NPI:1295334985
Name:BLANHETEAU, NICOLE N/A
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:N/A
Last Name:BLANHETEAU
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:N/A
Other - Last Name:BLANCHETEAU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSNICOLE
Mailing Address - Street 1:18518 MAYALL ST UNIT C
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91324-1432
Mailing Address - Country:US
Mailing Address - Phone:818-927-5562
Mailing Address - Fax:
Practice Address - Street 1:16500 VENTURA BLVD STE 414
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-5050
Practice Address - Country:US
Practice Address - Phone:818-788-1003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-22
Last Update Date:2020-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1124271614Medicaid