Provider Demographics
NPI:1407645138
Name:NIA, MICAH (AMFT)
Entity type:Individual
Prefix:
First Name:MICAH
Middle Name:
Last Name:NIA
Suffix:
Gender:
Credentials:AMFT
Other - Prefix:
Other - First Name:MICAH
Other - Middle Name:
Other - Last Name:FAHAR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:AMFT
Mailing Address - Street 1:18375 VENTURA BLVD # 1100
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4218
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9431 HAVEN AVE STE 100
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5879
Practice Address - Country:US
Practice Address - Phone:877-841-2034
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-30
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA152356106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist