Provider Demographics
NPI:1336497346
Name:HATIFIE, NISSA
Entity Type:Individual
Prefix:
First Name:NISSA
Middle Name:
Last Name:HATIFIE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1430 WILLOW PASS RD STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-7946
Mailing Address - Country:US
Mailing Address - Phone:925-288-3900
Mailing Address - Fax:
Practice Address - Street 1:1430 WILLOW PASS RD STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520-7946
Practice Address - Country:US
Practice Address - Phone:925-288-3900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-22
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X, 101YM0800X
103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health