Provider Demographics
NPI:1982317533
Name:ICHIKAWA, SAMANTHA
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:ICHIKAWA
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 1:1115 DECATUR ST
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-3607
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10125 S DE ANZA BLVD
Practice Address - Street 2:
Practice Address - City:CUPERTINO
Practice Address - State:CA
Practice Address - Zip Code:95014-2105
Practice Address - Country:US
Practice Address - Phone:408-865-1365
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-28
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21108225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty