Provider Demographics
NPI:1518367952
Name:ROSE, NICOLE M (MSW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:ROSE
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:M
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MSW
Mailing Address - Street 1:7264 OLYMPIC RD APT 102
Mailing Address - Street 2:
Mailing Address - City:JOSHUA TREE
Mailing Address - State:CA
Mailing Address - Zip Code:92252-2787
Mailing Address - Country:US
Mailing Address - Phone:760-910-5488
Mailing Address - Fax:
Practice Address - Street 1:58471 29 PALMS HWY STE 102
Practice Address - Street 2:
Practice Address - City:YUCCA VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92284-5818
Practice Address - Country:US
Practice Address - Phone:760-853-4888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-03
Last Update Date:2020-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 390200000X
CA738061041C0700X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA#95-2633765OtherMEDI-CAL