Healthcare Provider Details

I. General information

NPI: 1497204697
Provider Name (Legal Business Name): NICOLE GEND PSYD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2016
Last Update Date: 03/13/2026
Certification Date: 03/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30422 MALLORCA PL
CASTAIC CA
91384-4787
US

IV. Provider business mailing address

30422 MALLORCA PL
CASTAIC CA
91384-4787
US

V. Phone/Fax

Practice location:
  • Phone: 661-645-0872
  • Fax:
Mailing address:
  • Phone: 661-645-0872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number36629
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-16-23745
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: