Provider Demographics
NPI:1902971468
Name:ISHIBASHI, JUDITH (OTR,L)
Entity Type:Individual
Prefix:
First Name:JUDITH
Middle Name:
Last Name:ISHIBASHI
Suffix:
Gender:F
Credentials:OTR,L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W HUFFAKER LN
Mailing Address - Street 2:105
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89511-2092
Mailing Address - Country:US
Mailing Address - Phone:775-852-4342
Mailing Address - Fax:
Practice Address - Street 1:150 W HUFFAKER LN
Practice Address - Street 2:105
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89511-2092
Practice Address - Country:US
Practice Address - Phone:775-852-4342
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0001174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003416024Medicaid
NV003416024Medicaid
NVV102297Medicare Oscar/Certification