MEDICARE: DR. MAKOTO IKEGAMI DSW, MSW, LCSW

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	CW017519	PA
2	1041C0700X	Clinical Social Worker	SW14355	FL
3	1041C0700X	Clinical Social Worker	CSW006447	GA

General Provider Information

NPI Number	:	1932473113
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MAKOTO IKEGAMI DSW, MSW, LCSW

Provider Business Mailing Address
First Line	:	1901 ROSEWOOD RD
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30032-7017
Country	:	US
Telephone Number	:	470-763-5282
Fax Number	:

Provider Business Practice Location Address
First Line	:	1901 ROSEWOOD RD
Second Line	:
City	:	DECATUR
State	:	GA
Zip	:	30032-7017
Country	:	US
Telephone Number	:	470-763-5282
Fax Number	:

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

Provider Enumeration Date	:	03/06/2012
Last Update Date	:	01/09/2024

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