Provider Demographics
NPI:1447416375
Name:NISHIDA, TOMOKO
Entity Type:Individual
Prefix:
First Name:TOMOKO
Middle Name:
Last Name:NISHIDA
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 1:4875 N BACKER AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726-7507
Mailing Address - Country:US
Mailing Address - Phone:559-375-0704
Mailing Address - Fax:
Practice Address - Street 1:3147 N MILLBROOK AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93703-1425
Practice Address - Country:US
Practice Address - Phone:559-453-4309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 56924101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health