Basic Information
| Provider Information | |||||||||
| NPI: | 1184882607 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICKELS | ||||||||
| FirstName: | ELIZABETH | ||||||||
| MiddleName: | L. | ||||||||
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| Credential: | M.A., PSY.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2662 WALLACE ST | ||||||||
| Address2: | |||||||||
| City: | OAKLAND | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946063346 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5104142416 | ||||||||
| FaxNumber: | 5102506923 | ||||||||
| Practice Location | |||||||||
| Address1: | 400 ESTUDILLO AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945774962 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5107461188 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2008 | ||||||||
| LastUpdateDate: | 02/16/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/16/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | PSY22119 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.