Healthcare Provider Details

I. General information

NPI: 1659948875
Provider Name (Legal Business Name): MISS NICOL DE LA ROSA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2021
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 W GUTIERREZ ST
SANTA BARBARA CA
93101-3424
US

IV. Provider business mailing address

3601 CALLE TECATE
CAMARILLO CA
93012-5056
US

V. Phone/Fax

Practice location:
  • Phone: 805-965-1001
  • Fax:
Mailing address:
  • Phone: 805-289-0120
  • Fax: 805-289-0130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberAMFT151568
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: