Healthcare Provider Details

I. General information

NPI: 1205790698
Provider Name (Legal Business Name): MIEKO TAKEMOTO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2025
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2514 MARY ST
MONTROSE CA
91020-1125
US

IV. Provider business mailing address

2514 MARY ST
MONTROSE CA
91020-1125
US

V. Phone/Fax

Practice location:
  • Phone: 626-278-8437
  • Fax:
Mailing address:
  • Phone: 626-278-8437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number57556
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: