Healthcare Provider Details

I. General information

NPI: 1003299926
Provider Name (Legal Business Name): ASHLEY KIMIKO IKEDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2015
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3010 COLBY ST STE 221
BERKELEY CA
94705-2056
US

IV. Provider business mailing address

10 MOSS AVE APT 20
OAKLAND CA
94610-1300
US

V. Phone/Fax

Practice location:
  • Phone: 510-922-9757
  • Fax: 510-922-9514
Mailing address:
  • Phone: 415-225-8783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number120013
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: