Healthcare Provider Details

I. General information

NPI: 1336889963
Provider Name (Legal Business Name): TROY NICKELL FAMILY THERAPY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/31/2022
Last Update Date: 09/28/2022
Certification Date: 09/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

731 S HIGHWAY 101 STE 1E
SOLANA BEACH CA
92075-2628
US

IV. Provider business mailing address

721 KNIGHTSBRIDGE CT
CARDIFF CA
92007-1319
US

V. Phone/Fax

Practice location:
  • Phone: 858-314-8437
  • Fax:
Mailing address:
  • Phone: 760-815-2472
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number
License Number State

VIII. Authorized Official

Name: TROY NICKELL
Title or Position: PRESIDENT
Credential:
Phone: 858-314-8437