Provider Demographics
NPI:1396091724
Name:ASENCIO, NICOLE (PSYD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:
Last Name:ASENCIO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2423 CAMINO DEL RIO S STE 211
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-3735
Mailing Address - Country:US
Mailing Address - Phone:619-356-0185
Mailing Address - Fax:
Practice Address - Street 1:2423 CAMINO DEL RIO S STE 211
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3735
Practice Address - Country:US
Practice Address - Phone:619-356-0185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-03
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY002121106H00000X
CA99795106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist