Provider Demographics
NPI:1427214378
Name:NIKSEFAT, SAMIRA
Entity Type:Individual
Prefix:
First Name:SAMIRA
Middle Name:
Last Name:NIKSEFAT
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 1:5000 CHESHIRE PKWY N
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55446-4103
Mailing Address - Country:US
Mailing Address - Phone:888-510-0766
Mailing Address - Fax:763-268-4030
Practice Address - Street 1:1111 N BRAND BLVD
Practice Address - Street 2:STE L
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91202-3070
Practice Address - Country:US
Practice Address - Phone:818-244-7653
Practice Address - Fax:818-244-3229
Is Sole Proprietor?:No
Enumeration Date:2008-07-30
Last Update Date:2011-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU2206231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist