Provider Demographics
NPI:1770261109
Name:NIKOGOSYAN, MARIAM M
Entity type:Individual
Prefix:MS
First Name:MARIAM
Middle Name:M
Last Name:NIKOGOSYAN
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 1:81709 DR CARREON BLVD STE B1
Mailing Address - Street 2:
Mailing Address - City:INDIO
Mailing Address - State:CA
Mailing Address - Zip Code:92201-5510
Mailing Address - Country:US
Mailing Address - Phone:818-441-1049
Mailing Address - Fax:
Practice Address - Street 1:81709 DR CARREON BLVD STE B1
Practice Address - Street 2:
Practice Address - City:INDIO
Practice Address - State:CA
Practice Address - Zip Code:92201-5510
Practice Address - Country:US
Practice Address - Phone:760-347-0000
Practice Address - Fax:760-347-0020
Is Sole Proprietor?:No
Enumeration Date:2023-07-06
Last Update Date:2023-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2147NG1VMedicaid
CA33-11OtherDEPARTMENT OF HEALTH CARE SERVICES - NARCOTIC TREATMENT PROGRAM
CA-10404-MOtherSUBSTANCE ABUSE AND MENTAL HEALTH SERVICES ADMINISTRATION (SAMHSA)