Mimiko Watanabe

Primary specialty

Clinical PsychologistTaxonomy code 103TC0700X

License

PS019468 Issued in PA

Practice address

1411 S 15TH St
Philadelphia, PA 19146-4803

Phone

(646) 712-3919

NPI assigned

Sep 17, 2015

Sex

Female

Sole proprietor

No

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Addresses

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

Practice roles

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

• Watanabe Psychological Services, LLC

  • Clinical Psychologist
  • Upper Darby, PA
  • NPI 1942053749
  NPD Authorized official

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1442448000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1641427200000",
    "number": "1528437704",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "429 LITTLECROFT RD",
            "city": "UPPER DARBY",
            "state": "PA",
            "postal_code": "190824909",
            "telephone_number": "646-712-3919"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1411 S 15TH ST",
            "city": "PHILADELPHIA",
            "state": "PA",
            "postal_code": "191464803",
            "telephone_number": "646-712-3919"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "WATANABE",
        "first_name": "MIMIKO",
        "sole_proprietor": "NO",
        "sex": "F",
        "enumeration_date": "2015-09-17",
        "last_updated": "2022-01-06",
        "certification_date": "2022-01-06",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "390200000X",
            "taxonomy_group": "",
            "desc": "Student in an Organized Health Care Education/Training Program",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "103TC0700X",
            "taxonomy_group": "",
            "desc": "Psychologist, Clinical",
            "state": "PA",
            "license": "PS019468",
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Sophia Victoria Wasserwald, CRNP
• Emily Kathryn Wassmer, MD
• Jacqueline Wasynczuk, PHARMD
• Elizabeth Wat
• Meguru Watanabe, M.D.
• Tatsuya Watanabe, MD, PHD
• Jessica Watari, DO
• Watchful Homecare Organization LLC
• Eric Waterford
• Watermark Logan Partners, L.P. (The Springs at The Watermark)

• Clinical Psychologist in Philadelphia, PA
• Providers in Philadelphia, PA by specialty
• Clinical Psychologist in Pennsylvania

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Jan 6, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.