Basic Information
| Provider Information | |||||||||
| NPI: | 1104287721 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIRK | ||||||||
| FirstName: | NICK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 615 ENCINAL CT | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945973166 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6308904315 | ||||||||
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| Practice Location | |||||||||
| Address1: | 201 N CIVIC DR STE 183 | ||||||||
| Address2: | |||||||||
| City: | WALNUT CREEK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945963864 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9252999033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2016 | ||||||||
| LastUpdateDate: | 09/06/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | LMFT122998 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.