Provider Demographics
NPI:1053868489
Name:JOOSTEN, NICOLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:JOOSTEN
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 1:5235 KING AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:MD
Mailing Address - Zip Code:21237-4073
Mailing Address - Country:US
Mailing Address - Phone:518-461-8073
Mailing Address - Fax:
Practice Address - Street 1:5235 KING AVE STE 200
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:MD
Practice Address - Zip Code:21237-4073
Practice Address - Country:US
Practice Address - Phone:410-210-5557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-01
Last Update Date:2022-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810007762103T00000X
CT001641101YP2500X
GALPC006250101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional