Provider Demographics
NPI:1184059263
Name:PETIKAS, NICHOLAS CONSTANTINE (PHD, ABPP)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:CONSTANTINE
Last Name:PETIKAS
Suffix:
Gender:M
Credentials:PHD, ABPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1335 HOLLY AVE.
Mailing Address - Street 2:UNIT 2
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:91932
Mailing Address - Country:US
Mailing Address - Phone:516-369-3092
Mailing Address - Fax:
Practice Address - Street 1:NAVAL MEDICAL CENTER SAN DIEGO
Practice Address - Street 2:34800 BOB WILSON DR
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92134-0001
Practice Address - Country:US
Practice Address - Phone:619-453-6591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-09
Last Update Date:2022-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021404-01103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical