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NPI Code Detail

MEDICARE: DWAYNE NICKERSON

MEDICARE: DWAYNE NICKERSON
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1106H00000XMarriage & Family TherapistLMFT96210CA
2106H00000XMarriage & Family Therapist
3225400000XRehabilitation Practitioner

General Provider Information

NPI Number : 1780011437
Entity Type Code : Individual
Provider Name (Legal Business Name) : DWAYNE NICKERSON
Provider Business Mailing Address
First Line : 4193 FLAT ROCK DR STE 200
Second Line :
City : RIVERSIDE
State : CA
Zip : 92505-7113
Country : US
Telephone Number : 805-242-4851
Fax Number :
Provider Business Practice Location Address
First Line : 4193 FLAT ROCK DR STE 200
Second Line :
City : RIVERSIDE
State : CA
Zip : 92505-7113
Country : US
Telephone Number : 805-242-4851
Fax Number : 951-329-5800
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/26/2013
Last Update Date : 12/21/2023

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Directions to “ DWAYNE NICKERSON ” Practice Location

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