Provider Demographics
NPI:1790988137
Name:KNUDSEN, NICOLAS KENT (MFT)
Entity Type:Individual
Prefix:MR
First Name:NICOLAS
Middle Name:KENT
Last Name:KNUDSEN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39155 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1513
Mailing Address - Country:US
Mailing Address - Phone:415-377-5827
Mailing Address - Fax:415-377-5827
Practice Address - Street 1:39155 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1513
Practice Address - Country:US
Practice Address - Phone:415-377-5827
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-05
Last Update Date:2014-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC53922106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist