Provider Demographics
NPI:1902581572
Name:TAN, MIWAKO M (MT-BC)
Entity Type:Individual
Prefix:
First Name:MIWAKO
Middle Name:M
Last Name:TAN
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 ELEMENT WAY
Mailing Address - Street 2:
Mailing Address - City:DUBLIN
Mailing Address - State:CA
Mailing Address - Zip Code:94568-6743
Mailing Address - Country:US
Mailing Address - Phone:408-836-2832
Mailing Address - Fax:
Practice Address - Street 1:3400 ELEMENT WAY
Practice Address - Street 2:
Practice Address - City:DUBLIN
Practice Address - State:CA
Practice Address - Zip Code:94568-6743
Practice Address - Country:US
Practice Address - Phone:408-836-2832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-20
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17220225A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225A00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMusic Therapist