Provider Demographics
NPI:1457595639
Name:NICKS, SHIRLEY DIANNE (CMT)
Entity Type:Individual
Prefix:
First Name:SHIRLEY
Middle Name:DIANNE
Last Name:NICKS
Suffix:
Gender:F
Credentials:CMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8450 BUTTS CANYON ROAD
Mailing Address - Street 2:PO BOX 146
Mailing Address - City:POPE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94567
Mailing Address - Country:US
Mailing Address - Phone:707-965-9242
Mailing Address - Fax:707-965-9242
Practice Address - Street 1:8450 BUTTS CANYON ROAD
Practice Address - Street 2:
Practice Address - City:POPE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:94567
Practice Address - Country:US
Practice Address - Phone:707-965-9242
Practice Address - Fax:707-965-9242
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist