Provider Demographics
NPI:1154516052
Name:HUMPHREYS, NICOLE RYAN (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RYAN
Last Name:HUMPHREYS
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:RYAN
Other - Last Name:HUNT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:3102 E. HIGHLAND AVENUE
Mailing Address - Street 2:MEDICAL STAFF OFFICE
Mailing Address - City:PATTON
Mailing Address - State:CA
Mailing Address - Zip Code:92369
Mailing Address - Country:US
Mailing Address - Phone:909-425-7000
Mailing Address - Fax:
Practice Address - Street 1:3102 E. HIGHLAND AVENUE
Practice Address - Street 2:MEDICAL STAFF OFFICE
Practice Address - City:PATTON
Practice Address - State:CA
Practice Address - Zip Code:92369
Practice Address - Country:US
Practice Address - Phone:909-425-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-13
Last Update Date:2016-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041S0200X
CALCSW295571041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool