Provider Demographics
NPI:1871156364
Name:AHUMADA, ILSE (AA)
Entity type:Individual
Prefix:MS
First Name:ILSE
Middle Name:
Last Name:AHUMADA
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 ARKANSAS ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-3872
Mailing Address - Country:US
Mailing Address - Phone:707-805-6374
Mailing Address - Fax:
Practice Address - Street 1:1628 BROADWAY ST STE B
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2405
Practice Address - Country:US
Practice Address - Phone:707-649-8300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-19
Last Update Date:2019-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1285781217101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)