Provider Demographics
NPI:1508191446
Name:JOANN K. NISHIMOTO, PSYD, LLC
Entity Type:Organization
Organization Name:JOANN K. NISHIMOTO, PSYD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PSYCHOLOGIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JOANN
Authorized Official - Middle Name:K
Authorized Official - Last Name:NISHIMOTO
Authorized Official - Suffix:
Authorized Official - Credentials:PSYD
Authorized Official - Phone:847-337-7892
Mailing Address - Street 1:510 N LAKE ST STE 3
Mailing Address - Street 2:
Mailing Address - City:MUNDELEIN
Mailing Address - State:IL
Mailing Address - Zip Code:60060-1800
Mailing Address - Country:US
Mailing Address - Phone:847-337-7892
Mailing Address - Fax:
Practice Address - Street 1:510 N LAKE ST STE 3
Practice Address - Street 2:
Practice Address - City:MUNDELEIN
Practice Address - State:IL
Practice Address - Zip Code:60060-1800
Practice Address - Country:US
Practice Address - Phone:847-337-7892
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-09
Last Update Date:2009-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL071006907103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty