Healthcare Provider Details

I. General information

NPI: 1396894465
Provider Name (Legal Business Name): NASRIN NIKBIN MED
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 DIMOCK ST
ROXBURY MA
02119
US

IV. Provider business mailing address

55 DIMOCK STREET
ROXBURY MA
02119
US

V. Phone/Fax

Practice location:
  • Phone: 617-442-8800
  • Fax:
Mailing address:
  • Phone: 614-442-8800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberMASTERS
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: