Basic Information
| Provider Information | |||||||||
| NPI: | 1306202031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BARAB | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | STEVENSON | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | ASW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | BARAB | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | STEVENSON | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ASW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1551 ECHO PARK AVENUE | ||||||||
| Address2: | APT 312 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3017877626 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10428 LOWER AZUSA | ||||||||
| Address2: | PACIFIC CLINICS | ||||||||
| City: | EL MONTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264533399 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2016 | ||||||||
| LastUpdateDate: | 01/11/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW65978 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.