Provider Demographics
NPI:1457478760
Name:MIYAKE, MARIJANE (OTR)
Entity Type:Individual
Prefix:
First Name:MARIJANE
Middle Name:
Last Name:MIYAKE
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5242 ELKMONT DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO PALOS VERDES
Mailing Address - State:CA
Mailing Address - Zip Code:90275-2370
Mailing Address - Country:US
Mailing Address - Phone:310-375-7205
Mailing Address - Fax:
Practice Address - Street 1:5242 ELKMONT DR
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-2370
Practice Address - Country:US
Practice Address - Phone:310-375-7205
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1311225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation