Provider Demographics
NPI:1679675961
Name:NICKOLAISON, BRENDA (LCSW)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:NICKOLAISON
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12608 CAMPANA DR
Mailing Address - Street 2:
Mailing Address - City:DEL VALLE
Mailing Address - State:TX
Mailing Address - Zip Code:78617-3621
Mailing Address - Country:US
Mailing Address - Phone:402-730-1302
Mailing Address - Fax:
Practice Address - Street 1:4715 VIEWRIDGE AVE STE 230
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1680
Practice Address - Country:US
Practice Address - Phone:800-257-8715
Practice Address - Fax:800-819-1655
Is Sole Proprietor?:No
Enumeration Date:2006-09-05
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX408091041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical