Healthcare Provider Details

I. General information

NPI: 1316115090
Provider Name (Legal Business Name): MRS. NICOLLE LAREE MOYER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2008
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11057 BASYE ST
EL MONTE CA
91731-1655
US

IV. Provider business mailing address

11057 BASYE ST
EL MONTE CA
91731-1655
US

V. Phone/Fax

Practice location:
  • Phone: 626-444-0539
  • Fax: 626-444-7990
Mailing address:
  • Phone: 626-444-0539
  • Fax: 626-444-7990

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number63327
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: