Healthcare Provider Details

I. General information

NPI: 1912883885
Provider Name (Legal Business Name): NICHOLE MICHELLE STREETE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/14/2025
Last Update Date: 08/21/2025
Certification Date: 08/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4740 N GRAND AVE
COVINA CA
91724-2005
US

IV. Provider business mailing address

613 N KINSELLA AVE
COVINA CA
91724-2812
US

V. Phone/Fax

Practice location:
  • Phone: 626-859-2089
  • Fax:
Mailing address:
  • Phone: 408-833-2997
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number157403
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: