Provider Demographics
NPI:1174014252
Name:NICKLES, BRUCE CHARLES (MFT)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:CHARLES
Last Name:NICKLES
Suffix:
Gender:M
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:PO BOX 110681
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95011-0681
Mailing Address - Country:US
Mailing Address - Phone:408-593-1688
Mailing Address - Fax:
Practice Address - Street 1:151 W MISSION ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-1713
Practice Address - Country:US
Practice Address - Phone:408-535-4255
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39460106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty