Healthcare Provider Details

I. General information

NPI: 1609308758
Provider Name (Legal Business Name): NICOLE ROUSE MOTAKEF D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE CHRISTINA ROUSE D.O.

II. Dates (important events)

Enumeration Date: 03/29/2017
Last Update Date: 03/31/2026
Certification Date: 03/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21580 YORBA LINDA BLVD STE B
YORBA LINDA CA
92887-3748
US

IV. Provider business mailing address

21580 YORBA LINDA BLVD STE B
YORBA LINDA CA
92887-3748
US

V. Phone/Fax

Practice location:
  • Phone: 949-414-9495
  • Fax: 949-593-0312
Mailing address:
  • Phone: 949-414-9495
  • Fax: 949-593-0312

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number20A16793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: