Healthcare Provider Details

I. General information

NPI: 1912446121
Provider Name (Legal Business Name): KANAKO IWANAGA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/21/2017
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 KESSEL CT STE 105
MADISON WI
53711-6227
US

IV. Provider business mailing address

5002 SHEBOYGAN AVE APT 255
MADISON WI
53705-2816
US

V. Phone/Fax

Practice location:
  • Phone: 608-698-4912
  • Fax:
Mailing address:
  • Phone: 608-698-4912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: