MEDICARE: DR. RONALD KENJI MIYATAKE 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	1128	NH

General Provider Information

NPI Number	:	1730391822
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RONALD KENJI MIYATAKE PH.D.

Provider Business Mailing Address
First Line	:	222 WEST ST STE 29
Second Line	:
City	:	KEENE
State	:	NH
Zip	:	03431-2458
Country	:	US
Telephone Number	:	603-357-1180
Fax Number	:	603-357-1185

Provider Business Practice Location Address
First Line	:	222 WEST ST STE 29
Second Line	:
City	:	KEENE
State	:	NH
Zip	:	03431-2458
Country	:	US
Telephone Number	:	603-357-1180
Fax Number	:	603-357-1185

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

Provider Enumeration Date	:	05/03/2007
Last Update Date	:	07/08/2007

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