Provider Demographics
NPI:1174165369
Name:AZEVEDO, NICHOLAS
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:AZEVEDO
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 1:2275 ARLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1132
Mailing Address - Country:US
Mailing Address - Phone:510-317-1444
Mailing Address - Fax:
Practice Address - Street 1:995 POTRERO AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-2859
Practice Address - Country:US
Practice Address - Phone:415-934-7789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No172V00000XOther Service ProvidersCommunity Health Worker