MEDICARE: MIMIKO WATANABE

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	390200000X	Student in an Organized Health Care Education/Training Program
2	103TC0700X	Clinical Psychologist	PS019468	PA

General Provider Information

NPI Number	:	1528437704
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIMIKO WATANABE

Provider Business Mailing Address
First Line	:	429 LITTLECROFT RD
Second Line	:
City	:	UPPER DARBY
State	:	PA
Zip	:	19082-4909
Country	:	US
Telephone Number	:	646-712-3919
Fax Number	:

Provider Business Practice Location Address
First Line	:	1411 S 15TH ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19146-4803
Country	:	US
Telephone Number	:	646-712-3919
Fax Number	:

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

Provider Enumeration Date	:	09/17/2015
Last Update Date	:	01/06/2022

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Directions to “ MIMIKO WATANABE ” Practice Location

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