Provider Demographics
NPI:1780357848
Name:RADEMACHER, NICOLE ROSE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ROSE
Last Name:RADEMACHER
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 1:3651 S LA BREA AVE # 317
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90016-5311
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1704 WEST MANCHESTER AVE
Practice Address - Street 2:SUITE 202A
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-5311
Practice Address - Country:US
Practice Address - Phone:323-508-1924
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-26
Last Update Date:2021-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA126581106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty