MEDICARE: DR. KAY MIMAKI PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY18375	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11569035	OTHER	CA	CAQH

General Provider Information

NPI Number	:	1104966308
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KAY MIMAKI PH.D.

Provider Business Mailing Address
First Line	:	21213B HAWTHORNE BLVD
Second Line	:	#1142
City	:	TORRANCE
State	:	CA
Zip	:	90503
Country	:	US
Telephone Number	:	424-237-8811
Fax Number	:

Provider Business Practice Location Address
First Line	:	3611 MOTOR AVE STE 240
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-5887
Country	:	US
Telephone Number	:	310-421-8171
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/07/2007
Last Update Date	:	10/02/2024

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