Healthcare Provider Details

I. General information

NPI: 1275971335
Provider Name (Legal Business Name): NICOLE THERESE LEVEILLE PHD, PPS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2013
Last Update Date: 09/17/2021
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

511 S ORCHARD AVE
UKIAH CA
95482-3470
US

IV. Provider business mailing address

475 W CHURCH ST
UKIAH CA
95482-4817
US

V. Phone/Fax

Practice location:
  • Phone: 707-472-5000
  • Fax:
Mailing address:
  • Phone: 707-362-6808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: