Basic Information
Provider Information
NPI: 1003299926
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: IKEDA
FirstName: ASHLEY
MiddleName: KIMIKO
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
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OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 10 MOSS AVE APT 20
Address2:  
City: OAKLAND
State: CA
PostalCode: 946101300
CountryCode: US
TelephoneNumber: 4152258783
FaxNumber:  
Practice Location
Address1: 3010 COLBY ST STE 221
Address2:  
City: BERKELEY
State: CA
PostalCode: 947052056
CountryCode: US
TelephoneNumber: 5109229757
FaxNumber: 5109229514
Other Information
ProviderEnumerationDate: 07/09/2015
LastUpdateDate: 09/30/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 09/30/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106H00000X120013CAY Behavioral Health & Social Service ProvidersMarriage & Family Therapist 
390200000X  N Student, Health CareStudent in an Organized Health Care Education/Training Program 

No ID Information.


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