Healthcare Provider Details

I. General information

NPI: 1750854485
Provider Name (Legal Business Name): MIREI OGAWA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 PARKMOOR AVE STE 110
SAN JOSE CA
95126-3453
US

IV. Provider business mailing address

2165 ROYAL DR APT 2
SANTA CLARA CA
95050-3620
US

V. Phone/Fax

Practice location:
  • Phone: 408-885-0805
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: