Provider Demographics
NPI:1073029542
Name:NICKERSON, HEATHER (MA, RBT)
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MA, RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2810 SEASIDE WAY
Mailing Address - Street 2:
Mailing Address - City:CARLSBAD
Mailing Address - State:CA
Mailing Address - Zip Code:92010-7020
Mailing Address - Country:US
Mailing Address - Phone:209-482-3122
Mailing Address - Fax:
Practice Address - Street 1:3978 SORRENTO VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-1436
Practice Address - Country:US
Practice Address - Phone:858-428-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-12-20
Last Update Date:2017-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician