Basic Information
| Provider Information | |||||||||
| NPI: | 1265864268 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NEWCOMB | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | KATHLEEN | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PA-C, ASW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KATHOL | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | PA | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 10790 RANCHO BERNARDO RD | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921275705 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8586057171 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 278 TOWN CENTER PKWY | ||||||||
| Address2: | STE 105 (S90) | ||||||||
| City: | SANTEE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920715800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197137880 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2013 | ||||||||
| LastUpdateDate: | 06/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 06/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW62470 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 363AM0700X | PA56882 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
No ID Information.