Provider Demographics
NPI:1568735082
Name:EDWARDS, NICOLE F
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:F
Last Name:EDWARDS
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 1:400 ESTUDILLO AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-4999
Mailing Address - Country:US
Mailing Address - Phone:510-352-9200
Mailing Address - Fax:
Practice Address - Street 1:400 ESTUDILLO AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4999
Practice Address - Country:US
Practice Address - Phone:510-352-9200
Practice Address - Fax:510-352-3120
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
390200000X
CA115963106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program