Healthcare Provider Details

I. General information

NPI: 1326591777
Provider Name (Legal Business Name): NICOLE J KALLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 03/30/2023
Certification Date: 03/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2222 BANCROFT WAY FL 3
BERKELEY CA
94720-4301
US

IV. Provider business mailing address

1246 WALKER AVE APT 204
WALNUT CREEK CA
94596-4835
US

V. Phone/Fax

Practice location:
  • Phone: 510-642-9494
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number129667
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: