Provider Demographics
NPI:1902852940
Name:IKEDA, ANDREA (MS, CP, LP)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:
Last Name:IKEDA
Suffix:
Gender:F
Credentials:MS, CP, LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 N LARKIN AVE
Mailing Address - Street 2:STE. 207
Mailing Address - City:JOLIET
Mailing Address - State:IL
Mailing Address - Zip Code:60435-3438
Mailing Address - Country:US
Mailing Address - Phone:815-207-4200
Mailing Address - Fax:815-207-4100
Practice Address - Street 1:815 N LARKIN AVE
Practice Address - Street 2:STE. 207
Practice Address - City:JOLIET
Practice Address - State:IL
Practice Address - Zip Code:60435-3438
Practice Address - Country:US
Practice Address - Phone:815-207-4200
Practice Address - Fax:815-207-4100
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL09932112OtherBCBS
IL113671669001Medicaid
IL09932112OtherBCBS