Basic Information
Provider Information | |||||||||
NPI: | 1992259527 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | EXCONDE | ||||||||
FirstName: | NATHALIE | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | SOLIS | ||||||||
OtherFirstName: | NATHALIE | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | P.O. BOX 901961 | ||||||||
Address2: |   | ||||||||
City: | PALMDALE | ||||||||
State: | CA | ||||||||
PostalCode: | 935901961 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6612647165 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1529 EAST PALMDALE BLVD SUITE 150 | ||||||||
Address2: |   | ||||||||
City: | PALMDALE | ||||||||
State: | CA | ||||||||
PostalCode: | 93550 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6615751800 | ||||||||
FaxNumber: | 6612656025 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/11/2016 | ||||||||
LastUpdateDate: | 03/11/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/11/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 92645 | CA | N |   | Behavioral Health & Social Service Providers | Counselor | Mental Health | 101YM0800X | ASW92645 | CA | Y |   | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.