Provider Demographics
NPI:1154151033
Name:NICOLAS, LAURA
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:NICOLAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2847 GRACE ST APT 3
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-4744
Mailing Address - Country:US
Mailing Address - Phone:951-823-3519
Mailing Address - Fax:
Practice Address - Street 1:7365 CARNELIAN ST STE 202
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-1157
Practice Address - Country:US
Practice Address - Phone:909-281-1557
Practice Address - Fax:877-850-5695
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-05
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA148474106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist