Provider Demographics
NPI:1285826628
Name:MIWA, RIICHIRO (PSYD)
Entity Type:Individual
Prefix:DR
First Name:RIICHIRO
Middle Name:
Last Name:MIWA
Suffix:
Gender:M
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4540 CAMPUS DR # 146
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-1815
Mailing Address - Country:US
Mailing Address - Phone:310-254-4437
Mailing Address - Fax:
Practice Address - Street 1:4540 CAMPUS DR # 146
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-1815
Practice Address - Country:US
Practice Address - Phone:310-254-4437
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 21622103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist