Healthcare Provider Details

I. General information

NPI: 1609325364
Provider Name (Legal Business Name): MARISELA IBARRA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2016
Last Update Date: 02/24/2023
Certification Date: 02/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 W VICTORIA ST
GARDENA CA
90248-3523
US

IV. Provider business mailing address

8426 BOYNE ST
DOWNEY CA
90242-2504
US

V. Phone/Fax

Practice location:
  • Phone: 310-715-2020
  • Fax:
Mailing address:
  • Phone: 562-469-9564
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW111579
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: