Healthcare Provider Details

I. General information

NPI: 1255588919
Provider Name (Legal Business Name): MRS. NICOLE ROXANNE HOUGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MISS NICOLE ROXANNE DOLZADELL

II. Dates (important events)

Enumeration Date: 08/25/2008
Last Update Date: 08/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 NORTHPOINT PKWY
SANTA ROSA CA
95407
US

IV. Provider business mailing address

114 10TH ST
SANTA ROSA CA
95401-4716
US

V. Phone/Fax

Practice location:
  • Phone: 707-571-5581
  • Fax:
Mailing address:
  • Phone: 707-318-9425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: