Provider Demographics
NPI:1740933654
Name:SANTISTEBAN, NICOLE ALEXANDRA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ALEXANDRA
Last Name:SANTISTEBAN
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 1:3429 CANYON CREST DR # 5E
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3916
Mailing Address - Country:US
Mailing Address - Phone:213-361-6941
Mailing Address - Fax:
Practice Address - Street 1:21600 OXNARD ST STE 1030
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-5085
Practice Address - Country:US
Practice Address - Phone:877-206-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty