Provider Demographics
NPI:1417325051
Name:WETTACH-FARIAS, NICOLE
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:
Last Name:WETTACH-FARIAS
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 1:7811 BERNICE CT
Mailing Address - Street 2:
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-4021
Mailing Address - Country:US
Mailing Address - Phone:707-977-8611
Mailing Address - Fax:
Practice Address - Street 1:2455 BENNETT VALLEY RD STE B209
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95404-5669
Practice Address - Country:US
Practice Address - Phone:707-224-8266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-14
Last Update Date:2024-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127045104100000X
CA82369101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker