Healthcare Provider Details

I. General information

NPI: 1134044233
Provider Name (Legal Business Name): WATANABE PSYCHOLOGICAL SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/10/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

116 CLINTON ST
BROOKLYN NY
11201-4204
US

IV. Provider business mailing address

447 BROADWAY 2ND FLOOR #1407
NEW YORK NY
10013-2562
US

V. Phone/Fax

Practice location:
  • Phone: 215-550-1722
  • Fax:
Mailing address:
  • Phone: 215-550-1722
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State

VIII. Authorized Official

Name: DR. MIMIKO WATANABE
Title or Position: CLINICAL PSYCHOLOGIST
Credential: PSYD
Phone: 215-550-1722