Healthcare Provider Details

I. General information

NPI: 1629691126
Provider Name (Legal Business Name): RIKA TANAKA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2020
Last Update Date: 05/19/2020
Certification Date: 05/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

854 A AVE
CORONADO CA
92118-2646
US

IV. Provider business mailing address

PO BOX 182208
CORONADO CA
92178-2208
US

V. Phone/Fax

Practice location:
  • Phone: 619-354-4027
  • Fax:
Mailing address:
  • Phone: 619-354-4027
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TH0004X
TaxonomyHealth Psychologist
License NumberPSY30925
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY30925
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: