Provider Demographics
NPI:1265944904
Name:KANGAS, NICOLE LYNN (PHD, MA, JD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:LYNN
Last Name:KANGAS
Suffix:
Gender:F
Credentials:PHD, MA, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3465 HAMLIN RD
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CA
Mailing Address - Zip Code:94549-5018
Mailing Address - Country:US
Mailing Address - Phone:650-219-6018
Mailing Address - Fax:
Practice Address - Street 1:3744 MT DIABLO BLVD STE 206
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CA
Practice Address - Zip Code:94549-3614
Practice Address - Country:US
Practice Address - Phone:925-732-6878
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-03
Last Update Date:2017-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA102954106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist