Provider Demographics
NPI:1821852427
Name:ISHIKURA, SHO (LAC)
Entity Type:Individual
Prefix:
First Name:SHO
Middle Name:
Last Name:ISHIKURA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:748 NEW DURHAM RD
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2836
Mailing Address - Country:US
Mailing Address - Phone:929-382-2005
Mailing Address - Fax:
Practice Address - Street 1:221 RIVER ST STE 9
Practice Address - Street 2:
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-5990
Practice Address - Country:US
Practice Address - Phone:973-850-9104
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-13
Last Update Date:2024-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00732800101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor