Provider Demographics
NPI:1841324712
Name:NICKERSON, TRICIA L (MFT INTERN)
Entity type:Individual
Prefix:MS
First Name:TRICIA
Middle Name:L
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MFT INTERN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 EXECUTIVE PARK BLVD. SUITE 4900
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94134
Mailing Address - Country:US
Mailing Address - Phone:415-738-9099
Mailing Address - Fax:415-656-0117
Practice Address - Street 1:2513 24TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-3556
Practice Address - Country:US
Practice Address - Phone:415-652-8311
Practice Address - Fax:415-695-1263
Is Sole Proprietor?:No
Enumeration Date:2007-03-15
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5039101YM0800X
CA57151106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1309161Medicaid