Provider Demographics
NPI:1104966308
Name:MIMAKI, KAY (PHD)
Entity type:Individual
Prefix:DR
First Name:KAY
Middle Name:
Last Name:MIMAKI
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:KAY
Other - Middle Name:
Other - Last Name:TANAKA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:21213B HAWTHORNE BLVD
Mailing Address - Street 2:#1142
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90503
Mailing Address - Country:US
Mailing Address - Phone:424-237-8811
Mailing Address - Fax:
Practice Address - Street 1:3611 MOTOR AVE STE 240
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-5887
Practice Address - Country:US
Practice Address - Phone:310-421-8171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-07
Last Update Date:2024-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18375103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11569035OtherCAQH