Provider Demographics
NPI:1003190216
Name:MASSARI, NICOLE M (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:MASSARI
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2332 DEMARTINI LN
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-5389
Mailing Address - Country:US
Mailing Address - Phone:208-866-1822
Mailing Address - Fax:
Practice Address - Street 1:1210 CENTRAL BLVD STE 116
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:CA
Practice Address - Zip Code:94513-2360
Practice Address - Country:US
Practice Address - Phone:208-866-1822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-06
Last Update Date:2016-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLPC-4857101YP2500X
CA94904106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional