Provider Demographics
NPI:1205268539
Name:WHITMIRE, NIKOLUS (PSYD)
Entity type:Individual
Prefix:
First Name:NIKOLUS
Middle Name:
Last Name:WHITMIRE
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:NIKO
Other - Middle Name:
Other - Last Name:WHITMIRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PSYD
Mailing Address - Street 1:2991 SHATTUCK AVE STE 303
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-1872
Mailing Address - Country:US
Mailing Address - Phone:415-289-5928
Mailing Address - Fax:
Practice Address - Street 1:2991 SHATTUCK AVE STE 303
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-1872
Practice Address - Country:US
Practice Address - Phone:415-289-5928
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-09
Last Update Date:2022-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA31530103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program