Provider Demographics
NPI:1740489657
Name:MYRES, NIKKI
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:
Last Name:MYRES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 17TH ST # 203
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-4014
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5777 MADISON AVE
Practice Address - Street 2:240
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95841-3315
Practice Address - Country:US
Practice Address - Phone:916-344-0964
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-12
Last Update Date:2007-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 49378106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000008146OtherMEDI CAL PROVIDER NUMBER