Provider Demographics
NPI:1811216963
Name:NISHIMOTO, TAKAKO (MPT)
Entity Type:Individual
Prefix:
First Name:TAKAKO
Middle Name:
Last Name:NISHIMOTO
Suffix:
Gender:F
Credentials:MPT
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 27294
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92809-0108
Mailing Address - Country:US
Mailing Address - Phone:714-835-3500
Mailing Address - Fax:
Practice Address - Street 1:1206 E 17TH ST
Practice Address - Street 2:SUITE 204
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92701-2641
Practice Address - Country:US
Practice Address - Phone:714-835-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-27
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT35638225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist