Healthcare Provider Details

I. General information

NPI: 1538623004
Provider Name (Legal Business Name): BLANCA RUTH NICASSIO AMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/29/2019
Last Update Date: 09/25/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14677 MERRILL AVE
FONTANA CA
92335
US

IV. Provider business mailing address

9825 MAGNOLIA AVE STE B
RIVERSIDE CA
92503-3565
US

V. Phone/Fax

Practice location:
  • Phone: 951-643-2340
  • Fax:
Mailing address:
  • Phone: 951-509-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC6302
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number106568
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: