Provider Demographics
NPI:1811422058
Name:FIDEL, NICOLE DOMINGUEZ
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DOMINGUEZ
Last Name:FIDEL
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:700 GOLDEN SPRINGS DR UNIT E
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1173
Mailing Address - Country:US
Mailing Address - Phone:626-506-7186
Mailing Address - Fax:
Practice Address - Street 1:700 GOLDEN SPRINGS DR UNIT E
Practice Address - Street 2:
Practice Address - City:DIAMOND BAR
Practice Address - State:CA
Practice Address - Zip Code:91765-1173
Practice Address - Country:US
Practice Address - Phone:626-506-7186
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2025-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT121604101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7667OtherMEDI-CAL
CA7708OtherMEDI-CAL
CA7184OtherMEDI-CAL
CA7368OtherMEDI-CAL