Provider Demographics
NPI:1144903832
Name:NICOLETTE, DYLAN
Entity type:Individual
Prefix:
First Name:DYLAN
Middle Name:
Last Name:NICOLETTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 NIGHTINGALE DR
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-1712
Mailing Address - Country:US
Mailing Address - Phone:949-485-8269
Mailing Address - Fax:
Practice Address - Street 1:3714 S PARTON ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-4831
Practice Address - Country:US
Practice Address - Phone:657-294-5995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-09
Last Update Date:2023-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARH0011240823101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)