Provider Demographics
NPI:1962753566
Name:SCRUGGS, NICOLE RENEE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:RENEE
Last Name:SCRUGGS
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 1:130 EDGEHILL CT
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94589-2424
Mailing Address - Country:US
Mailing Address - Phone:707-704-2432
Mailing Address - Fax:
Practice Address - Street 1:111 MYRTLE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2525
Practice Address - Country:US
Practice Address - Phone:510-839-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-09-24
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health