Provider Demographics
NPI:1922456789
Name:IMHOF, NICOLE SYLVIA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SYLVIA
Last Name:IMHOF
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1529 E PALMDALE BLVD STE 210
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93550-2029
Mailing Address - Country:US
Mailing Address - Phone:661-272-9996
Mailing Address - Fax:
Practice Address - Street 1:1529 E PALMDALE BLVD
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93550-2034
Practice Address - Country:US
Practice Address - Phone:661-272-9996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF87651101YM0800X
CALMFT102212106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health