Healthcare Provider Details

I. General information

NPI: 1215414586
Provider Name (Legal Business Name): GIOVANNA CARMEN NICOLA-MENKE LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2018
Last Update Date: 07/19/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23041 AVENIDA DE LA CARLOTA
LAGUNA HILLS CA
92653-1511
US

IV. Provider business mailing address

23041 AVENIDA DE LA CARLOTA
LAGUNA HILLS CA
92653-1511
US

V. Phone/Fax

Practice location:
  • Phone: 714-644-6480
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT98766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: