Provider Demographics
NPI:1205420684
Name:ICE, EDEN SHANAY
Entity type:Individual
Prefix:
First Name:EDEN
Middle Name:SHANAY
Last Name:ICE
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 1:1390 SANTA ALICIA AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91913-1850
Mailing Address - Country:US
Mailing Address - Phone:619-455-2449
Mailing Address - Fax:
Practice Address - Street 1:1733 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-5414
Practice Address - Country:US
Practice Address - Phone:619-263-0433
Practice Address - Fax:619-263-3992
Is Sole Proprietor?:No
Enumeration Date:2021-02-25
Last Update Date:2025-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician