Provider Demographics
NPI:1417756057
Name:CHEATHAM, NICOLLE YVONNE (APCC)
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:YVONNE
Last Name:CHEATHAM
Suffix:
Gender:
Credentials:APCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:308 W AVENIDA VALENCIA
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92672-5446
Mailing Address - Country:US
Mailing Address - Phone:949-616-6068
Mailing Address - Fax:
Practice Address - Street 1:30240 RANCHO VIEJO RD STE C
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1515
Practice Address - Country:US
Practice Address - Phone:949-444-2576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-07
Last Update Date:2025-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC13349101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health