Provider Demographics
NPI:1912339540
Name:CHU, NICOLAS
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:
Last Name:CHU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 TAMAL VISTA BLVD STE 162
Mailing Address - Street 2:
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925-1146
Mailing Address - Country:US
Mailing Address - Phone:415-233-7990
Mailing Address - Fax:
Practice Address - Street 1:21 TAMAL VISTA BLVD STE 162
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1146
Practice Address - Country:US
Practice Address - Phone:415-233-7990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-06
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY29056103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical