Provider Demographics
NPI:1306202031
Name:BARAB, NICOLE STEVENSON (ASW)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:STEVENSON
Last Name:BARAB
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:MS
Other - First Name:NICOLE
Other - Middle Name:STEVENSON
Other - Last Name:BARAB
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ASW
Mailing Address - Street 1:1551 ECHO PARK AVENUE
Mailing Address - Street 2:APT 312
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026
Mailing Address - Country:US
Mailing Address - Phone:301-787-7626
Mailing Address - Fax:
Practice Address - Street 1:10428 LOWER AZUSA
Practice Address - Street 2:PACIFIC CLINICS
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91780
Practice Address - Country:US
Practice Address - Phone:626-453-3399
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-11
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW65978101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health