Provider Demographics
NPI:1083820625
Name:MACCALLUM, NICOLA (NICKY) (MFT)
Entity Type:Individual
Prefix:MS
First Name:NICOLA
Middle Name:(NICKY)
Last Name:MACCALLUM
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5332 COLLEGE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94618-2811
Mailing Address - Country:US
Mailing Address - Phone:510-594-0905
Mailing Address - Fax:
Practice Address - Street 1:5332 COLLEGE AVE STE 204
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618-2811
Practice Address - Country:US
Practice Address - Phone:510-594-0905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-14
Last Update Date:2012-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA31528106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist