Provider Demographics
NPI:1568785970
Name:KOYAMA, TAKAE (DPT)
Entity Type:Individual
Prefix:MS
First Name:TAKAE
Middle Name:
Last Name:KOYAMA
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:122 SWALLOWTAIL CT
Mailing Address - Street 2:
Mailing Address - City:BRISBANE
Mailing Address - State:CA
Mailing Address - Zip Code:94005-1259
Mailing Address - Country:US
Mailing Address - Phone:858-333-1029
Mailing Address - Fax:
Practice Address - Street 1:122 SWALLOWTAIL CT
Practice Address - Street 2:
Practice Address - City:BRISBANE
Practice Address - State:CA
Practice Address - Zip Code:94005-1259
Practice Address - Country:US
Practice Address - Phone:858-333-1029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-03-12
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA30155225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist