Healthcare Provider Details

I. General information

NPI: 1558043547
Provider Name (Legal Business Name): DESTINY KAYLA IBARRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2023
Last Update Date: 06/17/2026
Certification Date: 06/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 TECHNOLOGY CT
RIVERSIDE CA
92507-2155
US

IV. Provider business mailing address

555 TECHNOLOGY CT
RIVERSIDE CA
92507-2155
US

V. Phone/Fax

Practice location:
  • Phone: 951-686-8500
  • Fax:
Mailing address:
  • Phone: 951-686-8500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number132339
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: