Provider Demographics
NPI:1699161661
Name:RICHARDSON, NICOLE (SUDCC)
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:SUDCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:258 N KATHLEEN LN APT D
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92869-2529
Mailing Address - Country:US
Mailing Address - Phone:714-787-0247
Mailing Address - Fax:
Practice Address - Street 1:218 E COMMONWEALTH AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92832-1911
Practice Address - Country:US
Practice Address - Phone:714-992-4770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10165101YA0400X, 101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)