Provider Demographics
NPI:1417423401
Name:NASIRISHARGH, AIDA
Entity Type:Individual
Prefix:
First Name:AIDA
Middle Name:
Last Name:NASIRISHARGH
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 1:4150 V ST # 1100
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-1460
Mailing Address - Country:US
Mailing Address - Phone:916-734-2737
Mailing Address - Fax:
Practice Address - Street 1:4150 V ST # 1100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1460
Practice Address - Country:US
Practice Address - Phone:916-734-2737
Practice Address - Fax:916-734-2737
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-17
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18-67198106S00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician