Provider Demographics
NPI:1790300564
Name:USHIJIMA-MWESIGWA, KEIKO
Entity Type:Individual
Prefix:
First Name:KEIKO
Middle Name:
Last Name:USHIJIMA-MWESIGWA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 RIVER OAKS PKWY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95134-1907
Mailing Address - Country:US
Mailing Address - Phone:408-914-7478
Mailing Address - Fax:
Practice Address - Street 1:631 RIVER OAKS PKWY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95134-1907
Practice Address - Country:US
Practice Address - Phone:408-914-9153
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-08
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106E00000X
CARBT-17-36777106S00000X
CABACB376567103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician