Healthcare Provider Details

I. General information

NPI: 1659763282
Provider Name (Legal Business Name): MR. BERMAN IVAN ICABALCETA JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2015
Last Update Date: 05/29/2026
Certification Date: 05/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 SNEATH LN STE 307
SAN BRUNO CA
94066
US

IV. Provider business mailing address

1001 SNEATH LN STE 307
SAN BRUNO CA
94066-2349
US

V. Phone/Fax

Practice location:
  • Phone: 650-244-0305
  • Fax: 650-244-1447
Mailing address:
  • Phone: 650-244-0305
  • Fax: 650-244-1447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: