Provider Demographics
NPI:1538530274
Name:PEDERSON, NICOLE
Entity type:Individual
Prefix:MISS
First Name:NICOLE
Middle Name:
Last Name:PEDERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1147 LEIGH AVE
Mailing Address - Street 2:APT 3
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95126-4533
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1147 LEIGH AVE
Practice Address - Street 2:APT 3
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95126-4533
Practice Address - Country:US
Practice Address - Phone:925-337-0327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2016-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA103K00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No171M00000XOther Service ProvidersCase Manager/Care Coordinator