1396023982 NPI number — MS. BROOKE MICHELLE NIELSEN MFT INTERN

Table of content: MS. BROOKE MICHELLE NIELSEN MFT INTERN (NPI 1396023982)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1396023982 NPI number — MS. BROOKE MICHELLE NIELSEN MFT INTERN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NIELSEN
Provider First Name:
BROOKE
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
MFT INTERN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1396023982
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2089 CHATSWORTH BLVD APT 7
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92107-2740
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
858-876-5043
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
312 S. CEDROS AVE. STE 334
Provider Second Line Business Practice Location Address:
STE. 304
Provider Business Practice Location Address City Name:
SOLANA BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92107
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-876-5043
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/29/2011

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 106H00000X , with the licence number:  53345 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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