Provider Demographics
NPI:1417401910
Name:NICKEL-NGUY, MARY (MSSW, LICSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:
Last Name:NICKEL-NGUY
Suffix:
Gender:F
Credentials:MSSW, LICSW
Other - Prefix:MS
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:NGUY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSSW, LCSW
Mailing Address - Street 1:3065 FREEPORT BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95818-4347
Mailing Address - Country:US
Mailing Address - Phone:206-491-9710
Mailing Address - Fax:
Practice Address - Street 1:3065 FREEPORT BLVD STE 8
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95818-4347
Practice Address - Country:US
Practice Address - Phone:206-491-9710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-12
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW 603300231041C0700X
CA777751041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical