Individual
MIMIKO WATANABE
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
1411 S 15TH ST, PHILADELPHIA, PA 19146-4803
(646) 712-3919
Mailing address
429 LITTLECROFT RD, UPPER DARBY, PA 19082-4909
(646) 712-3919
Taxonomy
Speciality
Code
Description
License number
State
103TC0700X
Clinical Psychologist
Primary
PS019468
PA
390200000X
Student in an Organized Health Care Education/Training Program
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Other
Enumeration date
09/17/2015
Last updated
01/06/2022
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