Provider Demographics
NPI:1568172823
Name:MIYAMOTO, ANNIKA MARIKO (PSYD)
Entity Type:Individual
Prefix:
First Name:ANNIKA
Middle Name:MARIKO
Last Name:MIYAMOTO
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1271 WASHINGTON AVE # 719
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-3646
Mailing Address - Country:US
Mailing Address - Phone:707-495-6286
Mailing Address - Fax:
Practice Address - Street 1:3600 BROADWAY
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94611-5730
Practice Address - Country:US
Practice Address - Phone:510-752-7667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-28
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY33645103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical