Provider Demographics
NPI:1851609531
Name:REDZIC, NICOLE M (PSYD)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:REDZIC
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1306 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94122-2504
Mailing Address - Country:US
Mailing Address - Phone:650-687-7459
Mailing Address - Fax:
Practice Address - Street 1:845 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:MENLO PARK
Practice Address - State:CA
Practice Address - Zip Code:94025-4807
Practice Address - Country:US
Practice Address - Phone:650-687-7459
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-16
Last Update Date:2014-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL180.006807101Y00000X
390200000X
CAPSY 26259103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program