Provider Demographics
NPI:1053712380
Name:KUSTIC, NICOLE MARIE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:KUSTIC
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27890 CLINTON KEITH ROAD #449
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92562-9071
Mailing Address - Country:US
Mailing Address - Phone:951-290-2997
Mailing Address - Fax:
Practice Address - Street 1:41715 ENTERPRISE CIR N STE 102
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92590-5661
Practice Address - Country:US
Practice Address - Phone:951-290-2997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist