Provider Demographics
NPI:1609100833
Name:NICOL, MONICA
Entity Type:Individual
Prefix:MRS
First Name:MONICA
Middle Name:
Last Name:NICOL
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 1:544 W K ST
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-3067
Mailing Address - Country:US
Mailing Address - Phone:707-750-5108
Mailing Address - Fax:
Practice Address - Street 1:830 B ST
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-3003
Practice Address - Country:US
Practice Address - Phone:415-459-5843
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-21
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No251V00000XAgenciesVoluntary or Charitable