MEDICARE: DR. JOANN KENDRICK NISHIMOTO PSY.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	103TC0700X	Clinical Psychologist	071006907	IL

General Provider Information

NPI Number	:	1598913220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOANN KENDRICK NISHIMOTO PSY.D.

Provider Business Mailing Address
First Line	:	510 N LAKE ST
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-1865
Country	:	US
Telephone Number	:	847-337-7892
Fax Number	:

Provider Business Practice Location Address
First Line	:	510 N LAKE ST
Second Line	:
City	:	MUNDELEIN
State	:	IL
Zip	:	60060-1865
Country	:	US
Telephone Number	:	847-337-7892
Fax Number	:

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

Provider Enumeration Date	:	09/06/2008
Last Update Date	:	09/06/2008

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