Provider Demographics
NPI:1518367952
Name:ROSE, NICOLE M (LCSW)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ROSE
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:56925 YUCCA VALLEY TRAIL
Mailing Address - Street 2:PMB 513
Mailing Address - City:YUCCA VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92284
Mailing Address - Country:US
Mailing Address - Phone:760-910-5488
Mailing Address - Fax:
Practice Address - Street 1:7264 OLYMPIC RD APT 102
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-2787
Practice Address - Country:US
Practice Address - Phone:760-565-2325
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1065661041C0700X
CA738061041C0700X, 101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA#95-2633765OtherMEDI-CAL