Provider Demographics
NPI:1053764555
Name:KOOCHEKI, NAIEREH NINA
Entity type:Individual
Prefix:
First Name:NAIEREH
Middle Name:NINA
Last Name:KOOCHEKI
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 1:16260 VENTURA BLVD STE 600
Mailing Address - Street 2:SAME
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91436-4604
Mailing Address - Country:US
Mailing Address - Phone:818-986-1977
Mailing Address - Fax:818-986-4752
Practice Address - Street 1:16260 VENTURA BLVD#600
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-4604
Practice Address - Country:US
Practice Address - Phone:818-986-1977
Practice Address - Fax:818-986-4752
Is Sole Proprietor?:No
Enumeration Date:2016-07-20
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA308224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953995050Medicaid