Healthcare Provider Details

I. General information

NPI: 1851798383
Provider Name (Legal Business Name): JOHN IBARRA LMFT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/26/2014
Last Update Date: 05/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 AVENUE 64
PASADENA CA
91105
US

IV. Provider business mailing address

940 AVENUE 64
PASADENA CA
91105-2711
US

V. Phone/Fax

Practice location:
  • Phone: 323-543-2800
  • Fax:
Mailing address:
  • Phone: 323-543-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number76995
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number101607
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: