Provider Demographics
NPI:1588337810
Name:GAINES, NICHOLE THERESA
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:THERESA
Last Name:GAINES
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 1:58923 BUSINESS CENTER DR STE E
Mailing Address - Street 2:
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284-7311
Mailing Address - Country:US
Mailing Address - Phone:760-848-8480
Mailing Address - Fax:
Practice Address - Street 1:58923 BUSINESS CENTER DR STE E
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-7311
Practice Address - Country:US
Practice Address - Phone:760-848-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-02
Last Update Date:2021-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CA101Y00000X101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor