Provider Demographics
NPI:1619003258
Name:IBIRONKE, LATISHA FUNMILOLA
Entity Type:Individual
Prefix:
First Name:LATISHA
Middle Name:FUNMILOLA
Last Name:IBIRONKE
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 1:2323 HEARST AVE
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1319
Mailing Address - Country:US
Mailing Address - Phone:510-526-6200
Mailing Address - Fax:510-665-3176
Practice Address - Street 1:1820 SCENIC AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1324
Practice Address - Country:US
Practice Address - Phone:510-548-7270
Practice Address - Fax:510-841-4722
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA46518106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist