Healthcare Provider Details

I. General information

NPI: 1447589569
Provider Name (Legal Business Name): NICK ANTHONY BARNECLO PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2009
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 N CAMPO ST
LAS CRUCES NM
88001-3433
US

IV. Provider business mailing address

2301 CHAPEL DR
CAMARILLO CA
93010-7982
US

V. Phone/Fax

Practice location:
  • Phone: 575-650-0843
  • Fax: 805-419-6876
Mailing address:
  • Phone: 575-650-0843
  • Fax: 805-419-6876

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number1108
License Number StateNM
# 2
Primary TaxonomyN
Taxonomy Code103TC1900X
TaxonomyCounseling Psychologist
License NumberPSY28177
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: