Provider Demographics
NPI:1710050752
Name:NICKELL, TIMOTHY MARK (MHRS)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:MARK
Last Name:NICKELL
Suffix:
Gender:M
Credentials:MHRS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 KINGSTON AVE
Mailing Address - Street 2:APT 201
Mailing Address - City:PIEDMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94611-4457
Mailing Address - Country:US
Mailing Address - Phone:510-777-5374
Mailing Address - Fax:
Practice Address - Street 1:2275 ARLINGTON DR
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-1132
Practice Address - Country:US
Practice Address - Phone:510-317-1446
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health