Healthcare Provider Details

I. General information

NPI: 1417179102
Provider Name (Legal Business Name): CAROLYN NOLAN MFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 MEADOW LARK DR
SAN DIEGO CA
92123-2709
US

IV. Provider business mailing address

2901 MEADOW LARK DR 1ST FLOOR
SAN DIEGO CA
92123-2711
US

V. Phone/Fax

Practice location:
  • Phone: 858-694-4752
  • Fax: 858-514-8425
Mailing address:
  • Phone: 858-694-4752
  • Fax: 858-514-8425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC28488
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: