Provider Demographics
NPI:1285748913
Name:ROSKENS, NICOLE LYNN (MC, LPC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LYNN
Last Name:ROSKENS
Suffix:
Gender:F
Credentials:MC, LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 W OSBORN RD STE 230
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-3908
Mailing Address - Country:US
Mailing Address - Phone:602-405-9360
Mailing Address - Fax:
Practice Address - Street 1:240 W OSBORN RD STE 230
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-3908
Practice Address - Country:US
Practice Address - Phone:602-405-9360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-10823101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ201177Medicare ID - Type UnspecifiedCOUNSELING PROVIDER