Provider Demographics
NPI:1497420715
Name:NAGAYAMA, DEIRDRE
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:NAGAYAMA
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 1:4232 DAKE AVE
Mailing Address - Street 2:
Mailing Address - City:PALO ALTO
Mailing Address - State:CA
Mailing Address - Zip Code:94306-4617
Mailing Address - Country:US
Mailing Address - Phone:415-846-2549
Mailing Address - Fax:
Practice Address - Street 1:4232 DAKE AVE
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94306-4617
Practice Address - Country:US
Practice Address - Phone:415-846-2549
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-10
Last Update Date:2021-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAPCC7263101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAPCC7263Medicaid