Basic Information
| Provider Information | |||||||||
| NPI: | 1740708098 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PACIFICO | ||||||||
| FirstName: | NICOLLE | ||||||||
| MiddleName: | ANDREEA | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | PHD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BUGESCU | ||||||||
| OtherFirstName: | NICOLLE | ||||||||
| OtherMiddleName: | ANDREEA | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PHD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 4300 ROSE DR | ||||||||
| Address2: | |||||||||
| City: | YORBA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928862026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145284211 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4300 ROSE DR | ||||||||
| Address2: | |||||||||
| City: | YORBA LINDA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928862026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7145284211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2017 | ||||||||
| LastUpdateDate: | 05/13/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 05/13/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY29488 | CA | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.