Basic Information
| Provider Information | |||||||||
| NPI: | 1669847018 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KEADLE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | MISS | ||||||||
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| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 8030 SOQUEL AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950622096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314761747 | ||||||||
| FaxNumber: | 8314761125 | ||||||||
| Practice Location | |||||||||
| Address1: | 8030 SOQUEL AVE | ||||||||
| Address2: | SUITE 103 | ||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950622096 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314761747 | ||||||||
| FaxNumber: | 8314761125 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/10/2015 | ||||||||
| LastUpdateDate: | 12/10/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | RI-K1511041608 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.