Provider Demographics
NPI:1790113413
Name:KOMIYAMA, MASAKO (LICSW, ARNP)
Entity Type:Individual
Prefix:
First Name:MASAKO
Middle Name:
Last Name:KOMIYAMA
Suffix:
Gender:F
Credentials:LICSW, ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3639 MARTIN LUTHER KING JR WAY S
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98144-6847
Mailing Address - Country:US
Mailing Address - Phone:206-695-7600
Mailing Address - Fax:206-695-7606
Practice Address - Street 1:3639 MARTIN LUTHER KING JR WAY S
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98144
Practice Address - Country:US
Practice Address - Phone:206-695-7600
Practice Address - Fax:206-695-7606
Is Sole Proprietor?:No
Enumeration Date:2013-10-15
Last Update Date:2019-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA7430800211041C0700X
WAAP60994940363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical