Healthcare Provider Details

I. General information

NPI: 1063062297
Provider Name (Legal Business Name): NIKI ROSE MCMASTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2019
Last Update Date: 04/23/2025
Certification Date: 04/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 N ANAHEIM BLVD
ANAHEIM CA
92805-2651
US

IV. Provider business mailing address

710 N ANAHEIM BLVD UNIT 310
ANAHEIM CA
92805-2651
US

V. Phone/Fax

Practice location:
  • Phone: 714-776-7490
  • Fax:
Mailing address:
  • Phone: 714-776-7490
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number21258
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: