Healthcare Provider Details

I. General information

NPI: 1821955881
Provider Name (Legal Business Name): ANGELICA IBANEZ
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANGELICA BARAJAS

II. Dates (important events)

Enumeration Date: 01/09/2026
Last Update Date: 01/09/2026
Certification Date: 01/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6511 CLARKSBURG PL
STOCKTON CA
95207-3222
US

IV. Provider business mailing address

6511 CLARKSBURG PL
STOCKTON CA
95207-3222
US

V. Phone/Fax

Practice location:
  • Phone: 209-653-8776
  • Fax:
Mailing address:
  • Phone: 209-953-8776
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number230139099
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: