Provider Demographics
NPI:1386982239
Name:KLONCZ, NICOLE MARIE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:KLONCZ
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 1:103 D ST
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-6017
Mailing Address - Country:US
Mailing Address - Phone:530-671-3472
Mailing Address - Fax:
Practice Address - Street 1:201 D ST STE G
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:CA
Practice Address - Zip Code:95901-5957
Practice Address - Country:US
Practice Address - Phone:530-237-1715
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-28
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
CA118701106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor