=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003190216
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE M MASSARI LMFT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/06/2011
-----------------------------------------------------
Last Update Date | 09/06/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1210 CENTRAL BLVD STE 116
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94513-2360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-866-1822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2332 DEMARTINI LN
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94513-5389
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-866-1822
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number | LPC-4857
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | 94904
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------