Healthcare Provider Details

I. General information

NPI: 1679103444
Provider Name (Legal Business Name): NICOLE M CANTU
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2020
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 E DAKOTA AVE
FRESNO CA
93726-4821
US

IV. Provider business mailing address

1030 LYON AVE
SANGER CA
93657-2974
US

V. Phone/Fax

Practice location:
  • Phone: 559-600-9180
  • Fax:
Mailing address:
  • Phone: 559-273-7248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number10825
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: