Basic Information
| Provider Information | |||||||||
| NPI: | 1972021152 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBANEZ | ||||||||
| FirstName: | SERGIO | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | CM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1275 30TH ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921543476 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3025 BEYER BLVD STE E-101 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921543432 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6196624100 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/07/2017 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101YM0800X | 89362 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.