Provider Demographics
NPI:1417352501
Name:IKENASIO, KOSE (LCSW)
Entity type:Individual
Prefix:MR
First Name:KOSE
Middle Name:
Last Name:IKENASIO
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6401 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-4424
Mailing Address - Country:US
Mailing Address - Phone:951-276-7670
Mailing Address - Fax:
Practice Address - Street 1:6401 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4424
Practice Address - Country:US
Practice Address - Phone:951-276-7670
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-31
Last Update Date:2025-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA73873101YM0800X
1041S0200X
CA996201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool