Provider Demographics
NPI:1760142145
Name:MANSOURI, NIKA
Entity Type:Individual
Prefix:
First Name:NIKA
Middle Name:
Last Name:MANSOURI
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 1:133 LA MIRAGE CIR
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-4215
Mailing Address - Country:US
Mailing Address - Phone:203-506-2124
Mailing Address - Fax:
Practice Address - Street 1:133 LA MIRAGE CIR
Practice Address - Street 2:
Practice Address - City:ALISO VIEJO
Practice Address - State:CA
Practice Address - Zip Code:92656-4215
Practice Address - Country:US
Practice Address - Phone:203-506-2124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-27
Last Update Date:2021-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician