Healthcare Provider Details

I. General information

NPI: 1235076365
Provider Name (Legal Business Name): NCHELEM DIEDRE EHULE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2026
Last Update Date: 04/29/2026
Certification Date: 04/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1968 S COAST HWY # 2862
LAGUNA BEACH CA
92651-3681
US

IV. Provider business mailing address

11304 CHANDLER BLVD UNIT 713
NORTH HOLLYWOOD CA
91601-3127
US

V. Phone/Fax

Practice location:
  • Phone: 909-663-7422
  • Fax:
Mailing address:
  • Phone: 614-406-1572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: