Healthcare Provider Details

I. General information

NPI: 1154151033
Provider Name (Legal Business Name): LAURA NICOLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2024
Last Update Date: 08/06/2024
Certification Date: 08/06/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7365 CARNELIAN ST STE 202
RANCHO CUCAMONGA CA
91730-1157
US

IV. Provider business mailing address

2847 GRACE ST APT 3
RIVERSIDE CA
92504-4744
US

V. Phone/Fax

Practice location:
  • Phone: 909-281-1557
  • Fax: 877-850-5695
Mailing address:
  • Phone: 951-823-3519
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number148474
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: