Provider Demographics
NPI:1053942714
Name:TISSOT - DESMARAIS, NICOLLE DANIELLE
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:DANIELLE
Last Name:TISSOT - DESMARAIS
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 1:3468 MT DIABLO BLVD STE B301
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-7101
Mailing Address - Country:US
Mailing Address - Phone:925-297-5442
Mailing Address - Fax:
Practice Address - Street 1:3468 MT DIABLO BLVD STE B301
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-7101
Practice Address - Country:US
Practice Address - Phone:925-297-5442
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-31
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health