Healthcare Provider Details

I. General information

NPI: 1205420684
Provider Name (Legal Business Name): EDEN SHANAY ICE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2021
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1733 EUCLID AVE
SAN DIEGO CA
92105-5414
US

IV. Provider business mailing address

1390 SANTA ALICIA AVE
CHULA VISTA CA
91913-1850
US

V. Phone/Fax

Practice location:
  • Phone: 619-263-0433
  • Fax: 619-263-3992
Mailing address:
  • Phone: 619-455-2449
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: