Provider Demographics
NPI:1902171739
Name:NISHIMOTO, KRISTYN KEIKO
Entity Type:Individual
Prefix:
First Name:KRISTYN
Middle Name:KEIKO
Last Name:NISHIMOTO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9645 ARROW ROUTE
Mailing Address - Street 2:BLDG. 5, STE. A
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730
Mailing Address - Country:US
Mailing Address - Phone:909-948-9747
Mailing Address - Fax:
Practice Address - Street 1:9631 BUSINESS CENTER DRIVE
Practice Address - Street 2:BLDG. 14, STE. D
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730
Practice Address - Country:US
Practice Address - Phone:909-948-5747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-13
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
CA924991041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator