Provider Demographics
NPI:1801442314
Name:ISSAEVITCH, NICHOLETTE
Entity type:Individual
Prefix:
First Name:NICHOLETTE
Middle Name:
Last Name:ISSAEVITCH
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 1:1180 CURRIER AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93065-5104
Mailing Address - Country:US
Mailing Address - Phone:818-681-4012
Mailing Address - Fax:
Practice Address - Street 1:1180 CURRIER AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-5104
Practice Address - Country:US
Practice Address - Phone:818-681-4012
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-12
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA106H00000XOther95-2633765