Healthcare Provider Details

I. General information

NPI: 1558759068
Provider Name (Legal Business Name): MAKOTO WAKAMORI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2015
Last Update Date: 06/30/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6618 W CHICKASAW ST
PHOENIX AZ
85043-5755
US

IV. Provider business mailing address

6618 W CHICKASAW ST
PHOENIX AZ
85043-5755
US

V. Phone/Fax

Practice location:
  • Phone: 623-695-7663
  • Fax:
Mailing address:
  • Phone: 602-345-0240
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLPC-10550
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberLPC10550
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: