Provider Demographics
NPI:1164829677
Name:IKE, INNOCENT
Entity Type:Individual
Prefix:
First Name:INNOCENT
Middle Name:
Last Name:IKE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 MARTIN LUTHER KING JR DR SW
Mailing Address - Street 2:SUITE
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30310-1101
Mailing Address - Country:US
Mailing Address - Phone:404-564-6486
Mailing Address - Fax:404-564-6487
Practice Address - Street 1:2001 MARTIN LUTHER KING JR DR SW
Practice Address - Street 2:SUITE
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30310-1101
Practice Address - Country:US
Practice Address - Phone:404-564-6486
Practice Address - Fax:404-564-6487
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-26
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171W00000XOther Service ProvidersContractor
No172V00000XOther Service ProvidersCommunity Health Worker