MEDICARE: FATEMEH MAHTAB FARDANESH-NIKOO MA

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	101YM0800X	Mental Health Counselor		CA
2	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1437204047
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FATEMEH MAHTAB FARDANESH-NIKOO MA

Provider Business Mailing Address
First Line	:	250 EXECUTIVE PARK BLVD STE 4900
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94134-3335
Country	:	US
Telephone Number	:	415-341-2907
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 EXECUTIVE PARK BLVD STE 4900
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94134-3335
Country	:	US
Telephone Number	:	415-314-2907
Fax Number	:

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

Provider Enumeration Date	:	01/24/2007
Last Update Date	:	06/08/2023

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