Provider Demographics
NPI:1962250357
Name:DURAN, NICHOLE E (SUDRC# 17835)
Entity type:Individual
Prefix:
First Name:NICHOLE
Middle Name:E
Last Name:DURAN
Suffix:
Gender:F
Credentials:SUDRC# 17835
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 S M ST
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-6620
Mailing Address - Country:US
Mailing Address - Phone:805-736-0357
Mailing Address - Fax:866-543-5841
Practice Address - Street 1:113 S M ST
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-6620
Practice Address - Country:US
Practice Address - Phone:805-736-0357
Practice Address - Fax:866-543-5841
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-09
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
17835101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Single Specialty