MEDICARE: MS. KRISTYN NICOLE TANAKA-ROCHE MFT, ATR

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	106H00000X	Marriage & Family Therapist	82006	CA

General Provider Information

NPI Number	:	1124333968
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. KRISTYN NICOLE TANAKA-ROCHE MFT, ATR

Provider Business Mailing Address
First Line	:	3880 S BASCOM AVE STE 115
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95124-2600
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3880 S BASCOM AVE STE 115
Second Line	:
City	:	SAN JOSE
State	:	CA
Zip	:	95124-2600
Country	:	US
Telephone Number	:	408-351-1044
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/17/2010
Last Update Date	:	10/15/2021

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