Healthcare Provider Details

I. General information

NPI: 1932473113
Provider Name (Legal Business Name): MAKOTO IKEGAMI DSW, MSW, LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2012
Last Update Date: 11/04/2026
Certification Date: 11/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8735 DUNWOODY PL
SANDY SPRINGS GA
30350-2995
US

IV. Provider business mailing address

8735 DUNWOODY PL
SANDY SPRINGS GA
30350-2995
US

V. Phone/Fax

Practice location:
  • Phone: 470-763-5282
  • Fax:
Mailing address:
  • Phone: 470-763-5282
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCSW006447
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberCW017519
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberSW14355
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: