Provider Demographics
NPI:1679357503
Name:NICASSIO, LAURA JOANNE (MA AMFT)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:JOANNE
Last Name:NICASSIO
Suffix:
Gender:F
Credentials:MA AMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 936
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90714-0936
Mailing Address - Country:US
Mailing Address - Phone:562-279-3277
Mailing Address - Fax:
Practice Address - Street 1:2116 ARLINGTON AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90018-1300
Practice Address - Country:US
Practice Address - Phone:323-334-9000
Practice Address - Fax:323-334-4437
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X, 171M00000X
CA150598106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator