Provider Demographics
NPI:1982969226
Name:NICKERSON, RAYMOND JOSEPH (PSYD)
Entity Type:Individual
Prefix:MR
First Name:RAYMOND
Middle Name:JOSEPH
Last Name:NICKERSON
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 LAKESIDE DR
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-5774
Mailing Address - Country:US
Mailing Address - Phone:510-262-6551
Mailing Address - Fax:
Practice Address - Street 1:3095 RICHMOND PKWY STE 201
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-5878
Practice Address - Country:US
Practice Address - Phone:510-282-4211
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-12
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT47165106H00000X
CAPSY31676103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
1245393503OtherMEDICAL