Provider Demographics
NPI:1639219694
Name:NICKERSON, KATHLEEN ANNE (PHD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANNE
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:280 NEWPORT CENTER DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-7526
Mailing Address - Country:US
Mailing Address - Phone:949-222-6688
Mailing Address - Fax:949-716-7885
Practice Address - Street 1:280 NEWPORT CENTER DR
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7526
Practice Address - Country:US
Practice Address - Phone:949-222-6688
Practice Address - Fax:949-716-7885
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20446103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACP20446AMedicare ID - Type UnspecifiedMEDICARE PROVIDER