Provider Demographics
NPI:1932957701
Name:SAN NICOLAS, DOYLE (MA)
Entity Type:Individual
Prefix:PROF
First Name:DOYLE
Middle Name:
Last Name:SAN NICOLAS
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10630 N BANK DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-3212
Mailing Address - Country:US
Mailing Address - Phone:805-881-3404
Mailing Address - Fax:
Practice Address - Street 1:10630 N BANK DR
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-3212
Practice Address - Country:US
Practice Address - Phone:805-881-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-08
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16204101YP2500X
CA146109106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional