Provider Demographics
NPI:1003299926
Name:IKEDA, ASHLEY KIMIKO
Entity Type:Individual
Prefix:
First Name:ASHLEY
Middle Name:KIMIKO
Last Name:IKEDA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MOSS AVE APT 20
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94610-1300
Mailing Address - Country:US
Mailing Address - Phone:415-225-8783
Mailing Address - Fax:
Practice Address - Street 1:3010 COLBY ST STE 221
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2056
Practice Address - Country:US
Practice Address - Phone:510-922-9757
Practice Address - Fax:510-922-9514
Is Sole Proprietor?:No
Enumeration Date:2015-07-09
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CA120013106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program