Healthcare Provider Details

I. General information

NPI: 1396684718
Provider Name (Legal Business Name): NIKI NAKAMURA SUDRC I
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/28/2026
Last Update Date: 03/28/2026
Certification Date: 03/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 PALM AVE
SAN MATEO CA
94403-1814
US

IV. Provider business mailing address

PO BOX 620204
WOODSIDE CA
94062-0204
US

V. Phone/Fax

Practice location:
  • Phone: 650-513-6500
  • Fax:
Mailing address:
  • Phone: 650-640-6607
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number24352
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: