MEDICARE: TAKAHIDE TANAKA MSW

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	104100000X	Social Worker

General Provider Information

NPI Number	:	1881246197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TAKAHIDE TANAKA MSW

Provider Business Mailing Address
First Line	:	4225 CHESTNUT ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3014
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4225 CHESTNUT ST
Second Line	:
City	:	PHILADELPHIA
State	:	PA
Zip	:	19104-3014
Country	:	US
Telephone Number	:	215-386-1298
Fax Number	:

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

Provider Enumeration Date	:	07/16/2019
Last Update Date	:	07/16/2019

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