Healthcare Provider Details

I. General information

NPI: 1972156412
Provider Name (Legal Business Name): NICOLE SHOUMER MA, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 07/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11650 RIVERSIDE DR STE 10
STUDIO CITY CA
91602-1095
US

IV. Provider business mailing address

1323 SHADYBROOK DR
BEVERLY HILLS CA
90210-2031
US

V. Phone/Fax

Practice location:
  • Phone: 310-666-7288
  • Fax:
Mailing address:
  • Phone: 310-666-7288
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TB0200X
TaxonomyCognitive & Behavioral Psychologist
License NumberMFC114092
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberMFC114092
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: