Basic Information
| Provider Information | |||||||||
| NPI: | 1801374079 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALLISON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | DENISE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8350 ARCHIBALD AVE STE 125 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917307701 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 8350 ARCHIBALD AVE STE 125 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917307701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096894157 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/31/2018 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-20-46202 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst | 106S00000X | N |
No ID Information.