1528209954 NPI number — DR. DANIELLE RENE MIYASATO PHD

Table of content: DR. DANIELLE RENE MIYASATO PHD (NPI 1528209954)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528209954 NPI number — DR. DANIELLE RENE MIYASATO PHD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MIYASATO
Provider First Name:
DANIELLE
Provider Middle Name:
RENE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
PHD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MIYASATO
Provider Other First Name:
DANIELLE
Provider Other Middle Name:
RENE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
PHD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1528209954
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/30/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
357 DOLAN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MILL VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94941-3823
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-251-3808
Provider Business Mailing Address Fax Number:
415-408-7488

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
150 SHORELINE HWY
Provider Second Line Business Practice Location Address:
BUILDING B, STE 22B
Provider Business Practice Location Address City Name:
MILL VALLEY
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94941-3639
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
415-408-7488
Provider Business Practice Location Address Fax Number:
415-408-7488
Provider Enumeration Date:
03/16/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  PSY21712 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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