Provider Demographics
NPI:1437204047
Name:FARDANESH-NIKOO, FATEMEH MAHTAB (MA)
Entity Type:Individual
Prefix:
First Name:FATEMEH
Middle Name:MAHTAB
Last Name:FARDANESH-NIKOO
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 EXECUTIVE PARK BLVD STE 4900
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94134-3335
Mailing Address - Country:US
Mailing Address - Phone:415-341-2907
Mailing Address - Fax:
Practice Address - Street 1:250 EXECUTIVE PARK BLVD STE 4900
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94134-3335
Practice Address - Country:US
Practice Address - Phone:415-314-2907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2023-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
172V00000X, 172V00000X, 101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes172V00000XOther Service ProvidersCommunity Health Worker