Provider Demographics
NPI:1205986338
Name:IKEDA, LINDA MARIE (RN, MFT)
Entity type:Individual
Prefix:
First Name:LINDA
Middle Name:MARIE
Last Name:IKEDA
Suffix:
Gender:F
Credentials:RN, MFT
Other - Prefix:
Other - First Name:LINDA
Other - Middle Name:
Other - Last Name:IKEDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RN,MFT
Mailing Address - Street 1:1101 S WINCHESTER BLVD
Mailing Address - Street 2:K236
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-3901
Mailing Address - Country:US
Mailing Address - Phone:140-824-7160
Mailing Address - Fax:140-824-7160
Practice Address - Street 1:1101 S WINCHESTER BLVD.
Practice Address - Street 2:K236
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-3901
Practice Address - Country:US
Practice Address - Phone:140-824-7160
Practice Address - Fax:140-824-7160
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30391106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist