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NPI Code Detail

MEDICARE: MR. RAYMOND JOSEPH NICKERSON PSY.D.

MEDICARE: MR. RAYMOND JOSEPH NICKERSON PSY.D.
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
1106H00000XMarriage & Family TherapistLMFT47165CA
2103TC0700XClinical PsychologistPSY31676CA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11245393503OTHERMEDICAL

General Provider Information

NPI Number : 1982969226
Entity Type Code : Individual
Provider Name (Legal Business Name) : MR. RAYMOND JOSEPH NICKERSON PSY.D.
Provider Business Mailing Address
First Line : 4175 LAKESIDE DR
Second Line :
City : RICHMOND
State : CA
Zip : 94806-5774
Country : US
Telephone Number : 510-262-6551
Fax Number :
Provider Business Practice Location Address
First Line : 3095 RICHMOND PKWY STE 201
Second Line :
City : RICHMOND
State : CA
Zip : 94806-5878
Country : US
Telephone Number : 510-282-4211
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 07/12/2012
Last Update Date : 04/27/2020

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