MEDICARE: DR. LISA M NAKATA PH.D

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	103T00000X	Psychologist	PSY 17809	CA

General Provider Information

NPI Number	:	1306913769
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA M NAKATA PH.D

Provider Business Mailing Address
First Line	:	1761 BROADWAY ST STE 100
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94589-2227
Country	:	US
Telephone Number	:	707-645-2700
Fax Number	:

Provider Business Practice Location Address
First Line	:	1761 BROADWAY ST STE 100
Second Line	:
City	:	VALLEJO
State	:	CA
Zip	:	94589-2227
Country	:	US
Telephone Number	:	707-645-2700
Fax Number	:

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

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	01/03/2022

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