Provider Demographics
NPI:1548319650
Name:STATHAKOS, NICOLAS PETER (MA, MFT)
Entity type:Individual
Prefix:MR
First Name:NICOLAS
Middle Name:PETER
Last Name:STATHAKOS
Suffix:
Gender:M
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4200 PARK BLVD
Mailing Address - Street 2:STE. 265
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94602-1312
Mailing Address - Country:US
Mailing Address - Phone:510-710-6149
Mailing Address - Fax:
Practice Address - Street 1:1325 COLUMBUS AVE
Practice Address - Street 2:TOP FLOOR
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94133-1303
Practice Address - Country:US
Practice Address - Phone:415-460-5483
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39538106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist