Provider Demographics
NPI:1780011437
Name:NICKERSON, DWAYNE
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4193 FLAT ROCK DR STE 200
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-7113
Mailing Address - Country:US
Mailing Address - Phone:805-242-4851
Mailing Address - Fax:
Practice Address - Street 1:4193 FLAT ROCK DR STE 200
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-7113
Practice Address - Country:US
Practice Address - Phone:805-242-4851
Practice Address - Fax:951-329-5800
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-26
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT96210106H00000X
106H00000X, 225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner