Provider Demographics
NPI:1811123698
Name:WRIGHT, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WRIGHT
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 1:879 W 190TH ST STE 300
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-4223
Mailing Address - Country:US
Mailing Address - Phone:310-850-0115
Mailing Address - Fax:
Practice Address - Street 1:879 W 190TH ST STE 300
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90248-4223
Practice Address - Country:US
Practice Address - Phone:310-850-0115
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-07
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA112706101YM0800X, 1041C0700X
CAASW75318101YM0800X
390200000X
CA1211001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program