Healthcare Provider Details

I. General information

NPI: 1508134248
Provider Name (Legal Business Name): HISAKO OBA CMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/08/2011
Last Update Date: 12/08/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2718 TELEGRAPH AVE STE 103
BERKELEY CA
94705-1142
US

IV. Provider business mailing address

1159 HEARST AVE APT A
BERKELEY CA
94702-1621
US

V. Phone/Fax

Practice location:
  • Phone: 510-295-9820
  • Fax:
Mailing address:
  • Phone: 510-644-1530
  • Fax: 510-644-1530

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number12104
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: