Provider Demographics
NPI:1790399061
Name:TANABE, MIYU ROSIE (BSW)
Entity Type:Individual
Prefix:MISS
First Name:MIYU
Middle Name:ROSIE
Last Name:TANABE
Suffix:
Gender:F
Credentials:BSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2730 TORREY PINE DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92835-2848
Mailing Address - Country:US
Mailing Address - Phone:714-726-7549
Mailing Address - Fax:
Practice Address - Street 1:2730 TORREY PINE DR
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-2848
Practice Address - Country:US
Practice Address - Phone:714-726-7549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-03
Last Update Date:2020-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY2636026OtherDRIVERS LISCENCE