Provider Demographics
NPI:1215033550
Name:YAMAGUCHI, MITSUE Y (PHD)
Entity Type:Individual
Prefix:DR
First Name:MITSUE
Middle Name:Y
Last Name:YAMAGUCHI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 SKYPARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505
Mailing Address - Country:US
Mailing Address - Phone:310-257-5750
Mailing Address - Fax:310-257-5753
Practice Address - Street 1:3333 SKYPARK DRIVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505
Practice Address - Country:US
Practice Address - Phone:310-257-5750
Practice Address - Fax:310-257-5753
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY11911103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR16469Medicare UPIN
CACP11911DMedicare ID - Type Unspecified