Healthcare Provider Details

I. General information

NPI: 1053868489
Provider Name (Legal Business Name): NICOLE JOOSTEN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2016
Last Update Date: 02/28/2022
Certification Date: 02/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5235 KING AVE STE 200
ROSEDALE MD
21237-4073
US

IV. Provider business mailing address

5235 KING AVE STE 200
ROSEDALE MD
21237-4073
US

V. Phone/Fax

Practice location:
  • Phone: 410-210-5557
  • Fax:
Mailing address:
  • Phone: 518-461-8073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number001641
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC006250
License Number StateGA
# 3
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number0810007762
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: