Provider Demographics
NPI:1689705089
Name:SOSA, NICOLE ANNTOINETTE (MFT)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANNTOINETTE
Last Name:SOSA
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12450 VAN NUYS BLVD
Mailing Address - Street 2:#200
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1391
Mailing Address - Country:US
Mailing Address - Phone:818-896-1161
Mailing Address - Fax:818-896-5069
Practice Address - Street 1:12450 VAN NUYS BLVD
Practice Address - Street 2:#200
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1391
Practice Address - Country:US
Practice Address - Phone:818-896-1161
Practice Address - Fax:818-896-5069
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 48605106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7068Medicaid
CA7420Medicaid
CA6758Medicaid