Healthcare Provider Details

I. General information

NPI: 1790988137
Provider Name (Legal Business Name): NICOLAS KENT KNUDSEN MFT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 BANCROFT AVE
SAN LEANDRO CA
94577-6108
US

IV. Provider business mailing address

PO BOX 613
SAN LORENZO CA
94580-0613
US

V. Phone/Fax

Practice location:
  • Phone: 510-618-4600
  • Fax:
Mailing address:
  • Phone: 415-377-5827
  • Fax: 415-377-5827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number2301033783
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberMFC53922
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: