Provider Demographics
NPI:1336634419
Name:PALMER, NICHOLE KATHLEEN
Entity Type:Individual
Prefix:
First Name:NICHOLE
Middle Name:KATHLEEN
Last Name:PALMER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8304 WINDMILL FARMS DR
Mailing Address - Street 2:
Mailing Address - City:COTATI
Mailing Address - State:CA
Mailing Address - Zip Code:94931-4569
Mailing Address - Country:US
Mailing Address - Phone:650-207-4767
Mailing Address - Fax:
Practice Address - Street 1:3273 AIRWAY DR STE D
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2080
Practice Address - Country:US
Practice Address - Phone:650-207-4767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-29
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-18-58749106S00000X
CA138589106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician