Provider Demographics
NPI:1508256132
Name:SAVAGE, NICOLE A (RADRII)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:A
Last Name:SAVAGE
Suffix:
Gender:F
Credentials:RADRII
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 PAUL DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2023
Mailing Address - Country:US
Mailing Address - Phone:415-454-9444
Mailing Address - Fax:415-454-4864
Practice Address - Street 1:135 PAUL DR
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94903-2023
Practice Address - Country:US
Practice Address - Phone:415-454-9444
Practice Address - Fax:415-454-4864
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-03
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARII03130115324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility