Healthcare Provider Details

I. General information

NPI: 1487362190
Provider Name (Legal Business Name): IFUNANYA ROBINSON LICSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/10/2022
Last Update Date: 11/10/2022
Certification Date: 11/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19000 HOMESTEAD RD
CUPERTINO CA
95014-0712
US

IV. Provider business mailing address

348 S CLOVER AVE
SAN JOSE CA
95128-5118
US

V. Phone/Fax

Practice location:
  • Phone: 832-921-6963
  • Fax:
Mailing address:
  • Phone: 832-921-6963
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number60936420
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: