Healthcare Provider Details

I. General information

NPI: 1831494616
Provider Name (Legal Business Name): NICOLE JOHNSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/25/2011
Last Update Date: 07/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 E MINARETS AVE
PINEDALE CA
93650-1239
US

IV. Provider business mailing address

40 E MINARETS AVE
PINEDALE CA
93650-1239
US

V. Phone/Fax

Practice location:
  • Phone: 559-436-0482
  • Fax: 559-436-4650
Mailing address:
  • Phone: 559-436-0482
  • Fax: 559-436-4650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 66166
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: