=====================================================
General NPI Number Information
=====================================================
NPI Number | 1447048178
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MACARA MARIE NICOLL
-----------------------------------------------------
Gender |
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/30/2025
-----------------------------------------------------
Last Update Date | 04/30/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2121 CALAVERAS AVE
-----------------------------------------------------
City | DAVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95616-3071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-757-5430
-----------------------------------------------------
Fax | 530-757-5434
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2121 CALAVERAS AVE
-----------------------------------------------------
City | DAVIS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95616-3071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 530-757-5430
-----------------------------------------------------
Fax | 530-757-5434
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------