Healthcare Provider Details

I. General information

NPI: 1538631106
Provider Name (Legal Business Name): NICOLE E CARSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2018
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

145 W MAIN ST STE 200
TUSTIN CA
92780-4360
US

IV. Provider business mailing address

145 W MAIN ST STE 200
TUSTIN CA
92780-4360
US

V. Phone/Fax

Practice location:
  • Phone: 657-671-5687
  • Fax:
Mailing address:
  • Phone: 657-671-5687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: NICOLE CARSON
Title or Position: OWNER
Credential: LMFT, PPSC
Phone: 657-333-5805