Provider Demographics
NPI:1649870395
Name:LYNCH, NICOLE ANNA-MARIE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNA-MARIE
Last Name:LYNCH
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 1:16580 HARBOR BLVD STE M
Mailing Address - Street 2:
Mailing Address - City:FOUNTAIN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92708-1385
Mailing Address - Country:US
Mailing Address - Phone:714-975-5201
Mailing Address - Fax:
Practice Address - Street 1:16580 HARBOR BLVD STE M
Practice Address - Street 2:
Practice Address - City:FOUNTAIN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92708-1385
Practice Address - Country:US
Practice Address - Phone:714-975-5201
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-30
Last Update Date:2024-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA141462106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist