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General NPI Number Information
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NPI Number | 1649576851
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Entity Type | Individual
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Provider Name | ILKA LOUISE DE GAST PSYD
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Gender | Female
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Dates
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Enumeration Date | 02/04/2011
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Last Update Date | 05/13/2014
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Provider Practice Location Address
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Address Line | 3569 ROUND BARN CIR
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City | SANTA ROSA
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State | CA
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Zip | 95403-1757
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Country | US
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Telephone | 707-547-2222
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Fax | 707-527-0472
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Provider Business Mailing Address
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Address Line | 3569 ROUND BARN CIR
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City | SANTA ROSA
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State | CA
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Zip | 95403-1757
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Country | US
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Telephone | 707-547-2222
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Fax | 707-527-0472
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | PSB33686
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | PSY24409
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License Number State | CA
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