MEDICARE: MRS. TOMOKO NAKAMIZO-MUKASA M.A.

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	235Z00000X	Speech-Language Pathologist	SP15031	CA

General Provider Information

NPI Number	:	1487897120
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. TOMOKO NAKAMIZO-MUKASA M.A.

Provider Business Mailing Address
First Line	:	18350 MOUNT LANGLEY ST
Second Line	:	#105
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708-6900
Country	:	US
Telephone Number	:	714-965-2324
Fax Number	:	714-965-2684

Provider Business Practice Location Address
First Line	:	18350 MOUNT LANGLEY ST
Second Line	:	#105
City	:	FOUNTAIN VALLEY
State	:	CA
Zip	:	92708-6900
Country	:	US
Telephone Number	:	714-965-2324
Fax Number	:	714-965-2684

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

Provider Enumeration Date	:	04/10/2009
Last Update Date	:	04/10/2009

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