Provider Demographics
NPI:1093823429
Name:MIYAZAKI, IKUKO (MS)
Entity Type:Individual
Prefix:MS
First Name:IKUKO
Middle Name:
Last Name:MIYAZAKI
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:874 57TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95819-3327
Mailing Address - Country:US
Mailing Address - Phone:916-802-0233
Mailing Address - Fax:916-359-3265
Practice Address - Street 1:874 57TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3327
Practice Address - Country:US
Practice Address - Phone:916-802-0233
Practice Address - Fax:916-359-3265
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC36761106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist