Healthcare Provider Details

I. General information

NPI: 1730542382
Provider Name (Legal Business Name): MRS. NICOLE ANN CLELLAND
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: NICOLE ANN COSTA

II. Dates (important events)

Enumeration Date: 03/31/2016
Last Update Date: 10/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23832 ROCKFIELD BLVD STE 120
LAKE FOREST CA
92630-2870
US

IV. Provider business mailing address

23832 ROCKFIELD BLVD STE 120
LAKE FOREST CA
92630-2870
US

V. Phone/Fax

Practice location:
  • Phone: 949-415-4489
  • Fax:
Mailing address:
  • Phone: 949-415-4489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number101251
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number101251
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: