Provider Demographics
NPI:1194147116
Name:MIYAMOTO, KENJI CHRISTIAN (PHD)
Entity type:Individual
Prefix:DR
First Name:KENJI
Middle Name:CHRISTIAN
Last Name:MIYAMOTO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 E GRINNELL DR
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91501-1215
Mailing Address - Country:US
Mailing Address - Phone:818-846-2449
Mailing Address - Fax:
Practice Address - Street 1:1000 WILSHIRE BLVD STE 240
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-6279
Practice Address - Country:US
Practice Address - Phone:424-201-1600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-09
Last Update Date:2024-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
CA35078103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)