MEDICARE: REBECCA KIMIKO ISHIDA MFT

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	MFC36895	CA

General Provider Information

NPI Number	:	1730365545
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	REBECCA KIMIKO ISHIDA MFT

Provider Business Mailing Address
First Line	:	864 S ROBERTSON BLVD
Second Line	:	SUITE 300
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1605
Country	:	US
Telephone Number	:	310-358-0270
Fax Number	:	310-358-0245

Provider Business Practice Location Address
First Line	:	864 S ROBERTSON BLVD
Second Line	:	SUITE 300
City	:	LOS ANGELES
State	:	CA
Zip	:	90035-1605
Country	:	US
Telephone Number	:	310-358-0270
Fax Number	:	310-358-0245

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

Provider Enumeration Date	:	01/11/2008
Last Update Date	:	03/26/2008

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