Provider Demographics
NPI:1427126671
Name:EDWARDSON NICKEL, ELISE A (MPT PSYD)
Entity type:Individual
Prefix:DR
First Name:ELISE
Middle Name:A
Last Name:EDWARDSON NICKEL
Suffix:
Gender:F
Credentials:MPT PSYD
Other - Prefix:DR
Other - First Name:ELISE
Other - Middle Name:A
Other - Last Name:NICKEL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MPT PSYD
Mailing Address - Street 1:25149 HIGHSPRING AVE
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-3415
Mailing Address - Country:US
Mailing Address - Phone:661-255-3270
Mailing Address - Fax:661-255-3270
Practice Address - Street 1:25149 HIGHSPRING AVE
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-3415
Practice Address - Country:US
Practice Address - Phone:661-255-3270
Practice Address - Fax:661-255-3270
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT27138106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist