MEDICARE: WATARU NISHIDA MS, NCC, LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	PC014787	PA

General Provider Information

NPI Number	:	1194566141
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WATARU NISHIDA MS, NCC, LPC

Provider Business Mailing Address
First Line	:	1700 SPRING GARDEN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-3936
Country	:	US
Telephone Number	:	215-751-8167
Fax Number	:

Provider Business Practice Location Address
First Line	:	1700 SPRING GARDEN ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19130-3936
Country	:	US
Telephone Number	:	215-751-8167
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/04/2024
Last Update Date	:	06/04/2024

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