Provider Demographics
NPI:1992447080
Name:DESIMONE, NICOLE MICHELLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MICHELLE
Last Name:DESIMONE
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 1:11278 LOS ALAMITOS BLVD # 317
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-3958
Mailing Address - Country:US
Mailing Address - Phone:562-786-1343
Mailing Address - Fax:
Practice Address - Street 1:1370 BREA BLVD STE 132
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-4123
Practice Address - Country:US
Practice Address - Phone:562-786-1343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-10
Last Update Date:2022-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA132160106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist