Provider Demographics
NPI:1790145803
Name:NUCKOLS, BARBARA (MA)
Entity Type:Individual
Prefix:MRS
First Name:BARBARA
Middle Name:
Last Name:NUCKOLS
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10711 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-8733
Mailing Address - Country:US
Mailing Address - Phone:650-644-6167
Mailing Address - Fax:
Practice Address - Street 1:380 N MAIN ST
Practice Address - Street 2:SUITE H
Practice Address - City:LAKEPORT
Practice Address - State:CA
Practice Address - Zip Code:95453-4843
Practice Address - Country:US
Practice Address - Phone:707-879-8904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-02
Last Update Date:2016-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA77880106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist