Healthcare Provider Details

I. General information

NPI: 1356716039
Provider Name (Legal Business Name): NICOLE M. HISAKA M.A.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2015
Last Update Date: 10/27/2023
Certification Date: 07/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

760 WESTWOOD PLZ # A8-159
LOS ANGELES CA
90024-5055
US

IV. Provider business mailing address

5767 W CENTURY BLVD STE 400
LOS ANGELES CA
90045-5631
US

V. Phone/Fax

Practice location:
  • Phone: 310-794-0678
  • Fax:
Mailing address:
  • Phone: 310-301-8771
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number33188
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC2200X
TaxonomyClinical Child & Adolescent Psychologist
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: