Healthcare Provider Details

I. General information

NPI: 1154095701
Provider Name (Legal Business Name): NICHOLE CASSIDY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2021
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 MORENA BLVD
SAN DIEGO CA
92110-3815
US

IV. Provider business mailing address

11835 CARMEL MOUNTAIN RD STE 1304-410
SAN DIEGO CA
92128-4609
US

V. Phone/Fax

Practice location:
  • Phone: 619-692-8750
  • Fax:
Mailing address:
  • Phone: 760-496-8574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number164281
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: