Basic Information
| Provider Information | |||||||||
| NPI: | 1366647257 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GERDES | ||||||||
| FirstName: | NANCY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25910 ACERO STE 160 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926912777 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093357067 | ||||||||
| FaxNumber: | 9097922045 | ||||||||
| Practice Location | |||||||||
| Address1: | 1323 W COLTON AVE | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | REDLANDS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923744554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9097920747 | ||||||||
| FaxNumber: | 9097920033 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/19/2007 | ||||||||
| LastUpdateDate: | 07/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | CA | Y | Behavioral Health & Social Service Providers | Counselor |
ID Information
| ID | Type | State | Issuer | Description | 4529 | 01 | CA | SIMON STAFF NUMBER | OTHER |