Healthcare Provider Details

I. General information

NPI: 1154516052
Provider Name (Legal Business Name): NICOLE RYAN HUMPHREYS LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE RYAN HUNT LCSW

II. Dates (important events)

Enumeration Date: 09/13/2007
Last Update Date: 11/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3102 E. HIGHLAND AVENUE MEDICAL STAFF OFFICE
PATTON CA
92369
US

IV. Provider business mailing address

3102 E. HIGHLAND AVENUE MEDICAL STAFF OFFICE
PATTON CA
92369
US

V. Phone/Fax

Practice location:
  • Phone: 909-425-7000
  • Fax:
Mailing address:
  • Phone: 909-425-7000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW29557
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: