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General NPI Number Information
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NPI Number | 1194147116
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Entity Type | Individual
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Provider Name | KENJI CHRISTIAN MIYAMOTO PHD
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Gender | Male
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Dates
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Enumeration Date | 01/09/2014
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Last Update Date | 06/07/2024
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Provider Practice Location Address
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Address Line | 1000 WILSHIRE BLVD STE 240
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City | LOS ANGELES
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State | CA
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Zip | 90017-6279
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Country | US
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Telephone | 424-201-1600
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Fax |
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Provider Business Mailing Address
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Address Line | 833 E GRINNELL DR
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City | BURBANK
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State | CA
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Zip | 91501-1215
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Country | US
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Telephone | 818-846-2449
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 35078
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License Number State | CA
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