Healthcare Provider Details

I. General information

NPI: 1548026933
Provider Name (Legal Business Name): MARIANE MARGURETTE NICHOLSON SUDRC 17478
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 04/24/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 N ANAHEIM BLVD
ANAHEIM CA
92805-2651
US

IV. Provider business mailing address

710 N ANAHEIM BLVD
ANAHEIM CA
92805-2651
US

V. Phone/Fax

Practice location:
  • Phone: 714-776-7490
  • Fax:
Mailing address:
  • Phone: 714-776-7490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number17478
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: