Provider Demographics
NPI:1396819686
Name:HERZMARK, NICHOLAS JOSEPH (MFT)
Entity Type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:JOSEPH
Last Name:HERZMARK
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 1:227 MARIN ST
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-3713
Mailing Address - Country:US
Mailing Address - Phone:415-456-9553
Mailing Address - Fax:415-454-0520
Practice Address - Street 1:5845 COLLEGE AVE.
Practice Address - Street 2:SUITE 5
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94618
Practice Address - Country:US
Practice Address - Phone:510-869-4341
Practice Address - Fax:415-454-0520
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC31852101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health