=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932827482
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE DEFURIA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/19/2022
-----------------------------------------------------
Last Update Date | 10/21/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4701 E CESAR E CHAVEZ AVE
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90022-1209
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-881-3799
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 900 CORPORATE CENTER DR STE 350
-----------------------------------------------------
City | MONTEREY PARK
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91754-7620
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 323-526-4016
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | ASW123072
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------