Provider Demographics
NPI:1255740213
Name:OKAMOTO, MIA ANGELA (MS)
Entity type:Individual
Prefix:
First Name:MIA ANGELA
Middle Name:
Last Name:OKAMOTO
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:922 MOUNTAIN ASH TER UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SUNNYVALE
Mailing Address - State:CA
Mailing Address - Zip Code:94086-5170
Mailing Address - Country:US
Mailing Address - Phone:650-270-7010
Mailing Address - Fax:
Practice Address - Street 1:3170 DE LA CRUZ BLVD STE 107
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95054-2411
Practice Address - Country:US
Practice Address - Phone:669-253-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-04
Last Update Date:2023-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CABACB372691103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst