MEDICARE: NICHOLAS WIGHTMAN M.A., LMFT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	52065	CA

General Provider Information

NPI Number	:	1487892444
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICHOLAS WIGHTMAN M.A., LMFT

Provider Business Mailing Address
First Line	:	6355 TELEGRAPH AVE
Second Line	:	SUITE 301
City	:	OAKLAND
State	:	CA
Zip	:	94609-1371
Country	:	US
Telephone Number	:	510-717-9957
Fax Number	:

Provider Business Practice Location Address
First Line	:	6355 TELEGRAPH AVE
Second Line	:	SUITE 301
City	:	OAKLAND
State	:	CA
Zip	:	94609-1371
Country	:	US
Telephone Number	:	510-717-9957
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/29/2009
Last Update Date	:	05/03/2013

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