Provider Demographics
NPI:1184882607
Name:NICKELS, ELIZABETH L (MA, PSYD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:NICKELS
Suffix:
Gender:F
Credentials:MA, PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2662 WALLACE ST
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-3346
Mailing Address - Country:US
Mailing Address - Phone:510-414-2416
Mailing Address - Fax:510-250-6923
Practice Address - Street 1:400 ESTUDILLO AVE STE 100
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-4962
Practice Address - Country:US
Practice Address - Phone:510-746-1188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2021-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22119103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical