Provider Demographics
NPI:1972881431
Name:NICKERSON, TESHIONDA LABREA (MSW)
Entity Type:Individual
Prefix:MRS
First Name:TESHIONDA
Middle Name:LABREA
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3860 MIDDLEFIELD ROAD
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94303
Mailing Address - Country:US
Mailing Address - Phone:650-494-1200
Mailing Address - Fax:650-494-1243
Practice Address - Street 1:3860 MIDDLEFIELD RD
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94303-4716
Practice Address - Country:US
Practice Address - Phone:650-494-1200
Practice Address - Fax:650-494-1243
Is Sole Proprietor?:No
Enumeration Date:2011-08-01
Last Update Date:2011-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA01AVOtherMEDI-CAL PROVIDER NUMBER