Basic Information
| Provider Information | |||||||||
| NPI: | 1487234407 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RYMER CLARK | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ANGELYNNE | ||||||||
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| Credential: | SUDRC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2844 COLOMA ST | ||||||||
| Address2: | |||||||||
| City: | PLACERVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956674406 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5306138867 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5607 MT MURPHY RD | ||||||||
| Address2: | |||||||||
| City: | GARDEN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956339563 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303339460 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2021 | ||||||||
| LastUpdateDate: | 07/02/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/02/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | 11731 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.