Provider Demographics
NPI:1649163049
Name:FARSA, NIKKI RENEE
Entity type:Individual
Prefix:
First Name:NIKKI
Middle Name:RENEE
Last Name:FARSA
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 1:1022 SKY JASMINE WAY
Mailing Address - Street 2:
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94582-5076
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:14148 MAGNOLIA BLVD STE 103
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423-6414
Practice Address - Country:US
Practice Address - Phone:925-683-9290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-03
Last Update Date:2025-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician