Provider Demographics
NPI:1396896213
Name:DESAMPARO, NICOLE DENISE LOGGINS (MFTI)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DENISE LOGGINS
Last Name:DESAMPARO
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:DENISE
Other - Last Name:LOGGINS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:399 TAYLOR BLVD
Mailing Address - Street 2:SUITE 210
Mailing Address - City:PLEASANT HILL
Mailing Address - State:CA
Mailing Address - Zip Code:94523-2297
Mailing Address - Country:US
Mailing Address - Phone:925-482-6215
Mailing Address - Fax:
Practice Address - Street 1:399 TAYLOR BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:PLEASANT HILL
Practice Address - State:CA
Practice Address - Zip Code:94523-2297
Practice Address - Country:US
Practice Address - Phone:925-482-6215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2014-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 49753106H00000X
CAMFC48275106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4831OtherMEDI-CAL STAFF NUMBER