Provider Demographics
NPI:1891472809
Name:VINCENT, NITA JEAN
Entity Type:Individual
Prefix:
First Name:NITA
Middle Name:JEAN
Last Name:VINCENT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:NITA
Other - Middle Name:JEAN
Other - Last Name:MITCHELL-WHITE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:135 PAUL DR
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-2023
Mailing Address - Country:US
Mailing Address - Phone:415-492-4444
Mailing Address - Fax:415-492-8844
Practice Address - Street 1:1477 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-2028
Practice Address - Country:US
Practice Address - Phone:415-459-2395
Practice Address - Fax:415-459-1292
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-30
Last Update Date:2023-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210002FN101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1851510440Other2-ORG