Basic Information
| Provider Information | |||||||||
| NPI: | 1841324712 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NICKERSON | ||||||||
| FirstName: | TRICIA | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MFT INTERN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 EXECUTIVE PARK BLVD. SUITE 4900 | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94134 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4157389099 | ||||||||
| FaxNumber: | 4156560117 | ||||||||
| Practice Location | |||||||||
| Address1: | 2513 24TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN FRANCISCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 941103556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4156528311 | ||||||||
| FaxNumber: | 4156951263 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2007 | ||||||||
| LastUpdateDate: | 09/01/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 5039 | MA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 57151 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 1309161 | 05 | MA | MEDICAID |