Provider Demographics
NPI:1669789194
Name:SUCRE, NICOLE LARA (PSYD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:LARA
Last Name:SUCRE
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1700 PIERCE ST STE 103
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94115-3187
Mailing Address - Country:US
Mailing Address - Phone:415-999-3264
Mailing Address - Fax:415-901-0316
Practice Address - Street 1:1700 PIERCE ST STE 103
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3187
Practice Address - Country:US
Practice Address - Phone:415-999-3264
Practice Address - Fax:415-901-0316
Is Sole Proprietor?:Yes
Enumeration Date:2010-09-03
Last Update Date:2011-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23714103G00000X, 103TA0700X, 103TC0700X, 103TH0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist
No103TA0700XBehavioral Health & Social Service ProvidersPsychologistAdult Development & Aging
No103TH0004XBehavioral Health & Social Service ProvidersPsychologistHealth