Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 101YA0400X | Addiction Counselor (Substance Use Disorder) | 6917 | MA |
N | 101YM0800X | Mental Health Counselor | 6917 | MA |
N | 102L00000X | Psychologist | 6917 | MA |
N | 103T00000X | Psychologist | 6917 | MA |
N | 103TA0400X | Addiction Psychologist (Substance Use Disorder) | 6917 | MA |
N | 103TA0700X | Adult Development & Aging Psychologist | 6917 | MA |
Y | 103TB0200X | Cognitive & Behavioral Psychologist | 6917 | MA |
N | 103G00000X | Clinical Psychologist | 6917 | MA |
N | 103TC0700X | Clinical Psychologist | 6917 | MA |
N | 103TC1900X | Counseling Psychologist | 6917 | MA |
N | 103TC2200X | Clinical Child & Adolescent Psychologist | 6917 | MA |
N | 103TF0000X | Family Psychologist | 6917 | MA |
NPI | 1124146717 |
---|---|
Provider Name | Dr. Diana Hearst Ikeda |
First Address | Duxbury, MA 02331-2628 |
Second Address | Duxbury, MA 02332-5310 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 26/03/2007 |
Last Update Date | 13/12/2013 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
407109 | TUFTS BEHAVIORAL HEALTH (01) | MA |
W05211 | (05) | MA |
W05611 | BLUE CROSS BLUE SHIELD (01) | MA |