Provider Demographics
NPI:1568810489
Name:STORROW, NICOLE AXEL
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:AXEL
Last Name:STORROW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NICO
Other - Middle Name:AXEL
Other - Last Name:STORROW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 5101
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-0101
Mailing Address - Country:US
Mailing Address - Phone:510-982-1645
Mailing Address - Fax:
Practice Address - Street 1:1415 ADDISON STREET
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702
Practice Address - Country:US
Practice Address - Phone:510-982-1645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-01
Last Update Date:2022-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA127449106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist