Provider Demographics
NPI:1538390182
Name:IBUSUKI, TAKAKO (LCSW)
Entity type:Individual
Prefix:
First Name:TAKAKO
Middle Name:
Last Name:IBUSUKI
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:GRACE
Other - Middle Name:
Other - Last Name:IBUSUKI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17556 VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-6933
Mailing Address - Country:US
Mailing Address - Phone:310-809-7890
Mailing Address - Fax:
Practice Address - Street 1:17556 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-6933
Practice Address - Country:US
Practice Address - Phone:310-809-7890
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-30
Last Update Date:2009-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA255951041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical