Provider Demographics
NPI:1538502794
Name:KOSCIELAK, NICOLE DANIELLE
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:DANIELLE
Last Name:KOSCIELAK
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:NICOLE
Other - Middle Name:DANIELLE
Other - Last Name:BUSTAMANTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:11731 TELEGRAPH RD STE K
Mailing Address - Street 2:
Mailing Address - City:SANTA FE SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:90670-6815
Mailing Address - Country:US
Mailing Address - Phone:562-907-7429
Mailing Address - Fax:562-696-8640
Practice Address - Street 1:11731 TELEGRAPH RD STE K
Practice Address - Street 2:
Practice Address - City:SANTA FE SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:90670-6815
Practice Address - Country:US
Practice Address - Phone:562-907-7429
Practice Address - Fax:562-696-8640
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCSW804671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical