Healthcare Provider Details

I. General information

NPI: 1982969226
Provider Name (Legal Business Name): RAYMOND JOSEPH NICKERSON PSY.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2012
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3095 RICHMOND PKWY STE 201
RICHMOND CA
94806-5878
US

IV. Provider business mailing address

4175 LAKESIDE DR
RICHMOND CA
94806-5774
US

V. Phone/Fax

Practice location:
  • Phone: 510-282-4211
  • Fax:
Mailing address:
  • Phone: 510-262-6551
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberLMFT47165
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY31676
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: