Provider Demographics
NPI:1932486396
Name:IKUNAGA, AI (PSYD)
Entity Type:Individual
Prefix:DR
First Name:AI
Middle Name:
Last Name:IKUNAGA
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1518 WALNUT ST
Mailing Address - Street 2:SUITE 607
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19102-3419
Mailing Address - Country:US
Mailing Address - Phone:267-918-1428
Mailing Address - Fax:
Practice Address - Street 1:1518 WALNUT ST
Practice Address - Street 2:SUITE 607
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19102-3419
Practice Address - Country:US
Practice Address - Phone:267-918-1428
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-12
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPS016968103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical