MEDICARE: LATISHA FUNMILOLA IBIRONKE

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	106H00000X	Marriage & Family Therapist	46518	CA

General Provider Information

NPI Number	:	1619003258
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LATISHA FUNMILOLA IBIRONKE

Provider Business Mailing Address
First Line	:	2323 HEARST AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94709-1319
Country	:	US
Telephone Number	:	510-526-6200
Fax Number	:	510-665-3176

Provider Business Practice Location Address
First Line	:	1820 SCENIC AVE
Second Line	:
City	:	BERKELEY
State	:	CA
Zip	:	94709-1324
Country	:	US
Telephone Number	:	510-548-7270
Fax Number	:	510-841-4722

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	01/25/2018

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