Provider Demographics
NPI:1659698876
Name:IKEDA, SHANNON KEIKO
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:KEIKO
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 1:112 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:REDWOOD CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94062-3233
Mailing Address - Country:US
Mailing Address - Phone:650-931-6300
Mailing Address - Fax:650-228-0356
Practice Address - Street 1:1720 S AMPHLETT BLVD
Practice Address - Street 2:STE 250
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-2702
Practice Address - Country:US
Practice Address - Phone:650-931-6300
Practice Address - Fax:650-228-0356
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2016-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9954235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist