Basic Information
| Provider Information | |||||||||
| NPI: | 1730391822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MIYATAKE | ||||||||
| FirstName: | RONALD | ||||||||
| MiddleName: | KENJI | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 222 WEST ST STE 29 | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034312458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033571180 | ||||||||
| FaxNumber: | 6033571185 | ||||||||
| Practice Location | |||||||||
| Address1: | 222 WEST ST STE 29 | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 034312458 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033571180 | ||||||||
| FaxNumber: | 6033571185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TC0700X | 1128 | NH | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.