Provider Demographics
NPI:1417352501
Name:IKENASIO, KOSE (ACSW, MSW)
Entity Type:Individual
Prefix:
First Name:KOSE
Middle Name:
Last Name:IKENASIO
Suffix:
Gender:M
Credentials:ACSW, MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3171
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90711-3171
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:900 E GILBERT ST BLDG 5
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92415-0911
Practice Address - Country:US
Practice Address - Phone:909-387-7686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2017-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73873101YM0800X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health