Provider Demographics
NPI:1558759068
Name:WAKAMORI, MAKOTO
Entity Type:Individual
Prefix:
First Name:MAKOTO
Middle Name:
Last Name:WAKAMORI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17242 S HEALTHCARE DR
Mailing Address - Street 2:
Mailing Address - City:LAVEEN
Mailing Address - State:AZ
Mailing Address - Zip Code:85339-8501
Mailing Address - Country:US
Mailing Address - Phone:520-796-3860
Mailing Address - Fax:520-796-3801
Practice Address - Street 1:3850 NORTH 16TH STREET LAVEEN AZ 85339
Practice Address - Street 2:
Practice Address - City:LAVEEN
Practice Address - State:AZ
Practice Address - Zip Code:85339
Practice Address - Country:US
Practice Address - Phone:520-796-3860
Practice Address - Fax:520-796-3801
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-06
Last Update Date:2015-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLPC-10550101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional