Healthcare Provider Details

I. General information

NPI: 1073138442
Provider Name (Legal Business Name): MAKIKO WATANABE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2020
Last Update Date: 02/02/2022
Certification Date: 02/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 FRUIT ST
BOSTON MA
02114-2696
US

IV. Provider business mailing address

55 FRUIT ST
BOSTON MA
02114-2621
US

V. Phone/Fax

Practice location:
  • Phone: 617-724-6300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number11579
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: