Basic Information
| Provider Information | |||||||||
| NPI: | 1912279175 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBARRA | ||||||||
| FirstName: | BRENDA | ||||||||
| MiddleName: | LIZETH | ||||||||
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| Credential: | M.A. MFTI | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1908 BUSINESS CENTER DR | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098905930 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1908 BUSINESS CENTER DR | ||||||||
| Address2: | SUITE 220 | ||||||||
| City: | SAN BERNARDINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 924083436 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098905930 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/03/2012 | ||||||||
| LastUpdateDate: | 11/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 11/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 123669 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 67455 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 97583 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.