Provider Demographics
NPI:1497010268
Name:NISTOR, AMY DELENE (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:AMY
Middle Name:DELENE
Last Name:NISTOR
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1713
Mailing Address - Street 2:
Mailing Address - City:LOOMIS
Mailing Address - State:CA
Mailing Address - Zip Code:95650-1713
Mailing Address - Country:US
Mailing Address - Phone:916-807-4136
Mailing Address - Fax:
Practice Address - Street 1:1340 BLUE OAKS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95678-7035
Practice Address - Country:US
Practice Address - Phone:916-807-4136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-09
Last Update Date:2016-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA94544106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist