Healthcare Provider Details

I. General information

NPI: 1225066319
Provider Name (Legal Business Name): YASUSHI IWATA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2006
Last Update Date: 04/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 W 34TH ST PH
NEW YORK NY
10001-3006
US

IV. Provider business mailing address

19 W 34TH ST PH
NEW YORK NY
10001-3006
US

V. Phone/Fax

Practice location:
  • Phone: 646-209-2526
  • Fax:
Mailing address:
  • Phone: 646-209-2526
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number000335
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: