Healthcare Provider Details

I. General information

NPI: 1992474647
Provider Name (Legal Business Name): NICOLE QUINTAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/07/2021
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3454 HILLCREST AVE
ANTIOCH CA
94531-4263
US

IV. Provider business mailing address

758 ANTIGUA TER
MOUNTAIN HOUSE CA
95391-1259
US

V. Phone/Fax

Practice location:
  • Phone: 925-777-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number12062
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number12062
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number21585
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: