Healthcare Provider Details

I. General information

NPI: 1881246197
Provider Name (Legal Business Name): TAKAHIDE TANAKA MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2019
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4225 CHESTNUT ST
PHILADELPHIA PA
19104-3014
US

IV. Provider business mailing address

4225 CHESTNUT ST
PHILADELPHIA PA
19104-3014
US

V. Phone/Fax

Practice location:
  • Phone: 215-386-1298
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: