Provider Demographics
NPI:1114593076
Name:BERSEBACH, NIKOLAS TYLER
Entity Type:Individual
Prefix:
First Name:NIKOLAS
Middle Name:TYLER
Last Name:BERSEBACH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:134 OVAL RD
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-2462
Mailing Address - Country:US
Mailing Address - Phone:949-300-9054
Mailing Address - Fax:
Practice Address - Street 1:25201 PASEO DE ALICIA STE 110
Practice Address - Street 2:
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-4627
Practice Address - Country:US
Practice Address - Phone:949-300-9054
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2021-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician