Provider Demographics
NPI:1497362495
Name:MIYAKE, ELISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:ELISA
Middle Name:
Last Name:MIYAKE
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 1:2001 JUNIPERO SERRA BLVD STE 500
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94014-3888
Mailing Address - Country:US
Mailing Address - Phone:650-991-6135
Mailing Address - Fax:
Practice Address - Street 1:2001 JUNIPERO SERRA BLVD STE 500
Practice Address - Street 2:
Practice Address - City:DALY CITY
Practice Address - State:CA
Practice Address - Zip Code:94014-3888
Practice Address - Country:US
Practice Address - Phone:650-991-6135
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY31943103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling