MEDICARE: DR. NICOLE ASENCIO PSYD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	002121	NY
2	106H00000X	Marriage & Family Therapist	99795	CA

General Provider Information

NPI Number	:	1396091724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. NICOLE ASENCIO PSYD

Provider Business Mailing Address
First Line	:	2423 CAMINO DEL RIO S STE 211
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3735
Country	:	US
Telephone Number	:	619-356-0185
Fax Number	:

Provider Business Practice Location Address
First Line	:	2423 CAMINO DEL RIO S STE 211
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-3735
Country	:	US
Telephone Number	:	619-356-0185
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/03/2012
Last Update Date	:	06/01/2023

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