Provider Demographics
NPI:1821129891
Name:MATSUMOTO, NICOLE L (ASW)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:MATSUMOTO
Suffix:
Gender:F
Credentials:ASW
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:L
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:8836 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-4832
Mailing Address - Country:US
Mailing Address - Phone:323-751-3026
Mailing Address - Fax:323-751-3424
Practice Address - Street 1:8836 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-4832
Practice Address - Country:US
Practice Address - Phone:323-751-3026
Practice Address - Fax:323-751-3424
Is Sole Proprietor?:No
Enumeration Date:2007-03-08
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA33736104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW 33736OtherASSOCIAL CLINICAL SOCIAL WORKER REGISTRATION NUMBER -