Provider Demographics
NPI:1053560573
Name:NICKERSON, MOLLY BETH (MSW, ACSW)
Entity type:Individual
Prefix:MS
First Name:MOLLY
Middle Name:BETH
Last Name:NICKERSON
Suffix:
Gender:F
Credentials:MSW, ACSW
Other - Prefix:MS
Other - First Name:MOLLY
Other - Middle Name:BETH
Other - Last Name:NICKERSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSW, ACSW
Mailing Address - Street 1:601 S PROSPECT AVE
Mailing Address - Street 2:UNIT 306
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90277-4456
Mailing Address - Country:US
Mailing Address - Phone:310-793-6360
Mailing Address - Fax:
Practice Address - Street 1:923 S CATALINA AVE
Practice Address - Street 2:
Practice Address - City:REDONDO BEACH
Practice Address - State:CA
Practice Address - Zip Code:90277-4718
Practice Address - Country:US
Practice Address - Phone:310-792-5454
Practice Address - Fax:310-792-5463
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-09
Last Update Date:2017-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1053560573Medicaid