Healthcare Provider Details

I. General information

NPI: 1033035548
Provider Name (Legal Business Name): MARY BARAYEKERE NICKSAGBE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 AUSTIN AVE APT 434
HAYWARD CA
94544-2271
US

IV. Provider business mailing address

50 AUSTIN AVE APT 434
HAYWARD CA
94544-2271
US

V. Phone/Fax

Practice location:
  • Phone: 317-748-3298
  • Fax:
Mailing address:
  • Phone: 317-748-3298
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number717880
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: