Provider Demographics
NPI:1154578474
Name:NISSEN, VICKI I (LCSW)
Entity type:Individual
Prefix:MS
First Name:VICKI
Middle Name:I
Last Name:NISSEN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6816 HYDE PARK DR UNIT S
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-2249
Mailing Address - Country:US
Mailing Address - Phone:619-462-6815
Mailing Address - Fax:
Practice Address - Street 1:6816 HYDE PARK DR UNIT S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92119-2249
Practice Address - Country:US
Practice Address - Phone:619-462-6815
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-19
Last Update Date:2008-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS131261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical