MEDICARE: TRACI KEIKO ISHIGO MSW

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	83877	CA

General Provider Information

NPI Number	:	1497385199
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TRACI KEIKO ISHIGO MSW

Provider Business Mailing Address
First Line	:	3371 GLENDALE BLVD STE 214
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-1857
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3371 GLENDALE BLVD STE 214
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90039-1857
Country	:	US
Telephone Number	:	562-661-9813
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/22/2020
Last Update Date	:	01/22/2020

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