=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629691126
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RIKA TANAKA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2020
-----------------------------------------------------
Last Update Date | 05/19/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 854 A AVE
-----------------------------------------------------
City | CORONADO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92118-2646
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-354-4027
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 182208
-----------------------------------------------------
City | CORONADO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92178-2208
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-354-4027
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TH0004X
-----------------------------------------------------
Taxonomy Name | Health Psychologist
-----------------------------------------------------
License Number | PSY30925
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY30925
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------