Basic Information
| Provider Information | |||||||||
| NPI: | 1851489579 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CULLY | ||||||||
| FirstName: | NYCOLE | ||||||||
| MiddleName: | TILISA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 115 ARRAN AVE | ||||||||
| Address2: | |||||||||
| City: | SPRING VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919776404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9092124437 | ||||||||
| FaxNumber: | 9092124437 | ||||||||
| Practice Location | |||||||||
| Address1: | 9445 FARNHAM ST STE 100 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583804676 | ||||||||
| FaxNumber: | 8583804676 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2006 | ||||||||
| LastUpdateDate: | 02/24/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.