Provider Demographics
NPI:1912537424
Name:EGE, MIYUKI N (MA)
Entity Type:Individual
Prefix:
First Name:MIYUKI
Middle Name:N
Last Name:EGE
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:MIYUKI
Other - Middle Name:
Other - Last Name:NAKAMURA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MA
Mailing Address - Street 1:4605 MACCORKLE AVE SW OFC
Mailing Address - Street 2:
Mailing Address - City:SOUTH CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25309-1311
Mailing Address - Country:US
Mailing Address - Phone:304-414-4800
Mailing Address - Fax:
Practice Address - Street 1:333 LAIDLEY ST FL 4E
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25301-1614
Practice Address - Country:US
Practice Address - Phone:304-766-4560
Practice Address - Fax:304-766-4599
Is Sole Proprietor?:No
Enumeration Date:2020-01-23
Last Update Date:2021-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV1228103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1228OtherWV LICENSE