Healthcare Provider Details

I. General information

NPI: 1679763510
Provider Name (Legal Business Name): MITSUAKI KAYNE OHATA PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2007
Last Update Date: 12/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 TOMMYDON ST
STOCKTON CA
95210-3364
US

IV. Provider business mailing address

1305 TOMMYDON ST
STOCKTON CA
95210-3364
US

V. Phone/Fax

Practice location:
  • Phone: 209-476-3876
  • Fax:
Mailing address:
  • Phone: 209-476-3876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY21574
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: