Healthcare Provider Details

I. General information

NPI: 1235946146
Provider Name (Legal Business Name): NICOLE TOBIASON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2024
Last Update Date: 01/12/2026
Certification Date: 01/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

41820 GARSTIN DR
BIG BEAR LAKE CA
92315
US

IV. Provider business mailing address

PO BOX 6609
BIG BEAR LAKE CA
92315-6609
US

V. Phone/Fax

Practice location:
  • Phone: 909-744-0223
  • Fax:
Mailing address:
  • Phone: 909-744-0223
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-YOGPJZ
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1594030125
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: