Provider Demographics
NPI:1144313651
Name:BYWATER, NICKI A (LMFT)
Entity type:Individual
Prefix:
First Name:NICKI
Middle Name:A
Last Name:BYWATER
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16520 WAGON WHEEL DR
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505
Mailing Address - Country:US
Mailing Address - Phone:951-858-4999
Mailing Address - Fax:951-787-1191
Practice Address - Street 1:5790 MAGNOLIA AVE #202
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:951-858-4999
Practice Address - Fax:951-682-0519
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39487106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist