Provider Demographics
NPI:1578910444
Name:NICHOLS, GRACE (MA)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:NICHOLS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2258 CAMINO RAMON
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1353
Mailing Address - Country:US
Mailing Address - Phone:206-375-0480
Mailing Address - Fax:
Practice Address - Street 1:2258 CAMINO RAMON
Practice Address - Street 2:
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-1353
Practice Address - Country:US
Practice Address - Phone:206-375-0480
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-19
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF86143101YP2500X
CA109372106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional