Healthcare Provider Details

I. General information

NPI: 1760556468
Provider Name (Legal Business Name): RICHARD NYBERG MSW, MDIV.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 12/06/2021
Certification Date: 12/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 DOVE ST SUITE 150
NEWPORT BEACH CA
92660-3023
US

IV. Provider business mailing address

901 DOVE ST SUITE 150
NEWPORT BEACH CA
92660-3023
US

V. Phone/Fax

Practice location:
  • Phone: 949-222-2292
  • Fax: 949-222-0411
Mailing address:
  • Phone: 949-222-2292
  • Fax: 949-222-0411

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLL7587
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMR 14179
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: