Basic Information
| Provider Information | |||||||||
| NPI: | 1518367952 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROSE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ROSE | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 7264 OLYMPIC RD APT 102 | ||||||||
| Address2: | |||||||||
| City: | JOSHUA TREE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922522787 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609105488 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 58471 29 PALMS HWY STE 102 | ||||||||
| Address2: | |||||||||
| City: | YUCCA VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922845818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608534888 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/03/2014 | ||||||||
| LastUpdateDate: | 07/13/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 1041C0700X | 73806 | CA | N | Behavioral Health & Social Service Providers | Social Worker | Clinical | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | 73806 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | #95-2633765 | 01 | CA | MEDI-CAL | OTHER |