Provider Demographics
NPI:1194064295
Name:CARRASCO, IVAN GABRIEL (LMFT)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:GABRIEL
Last Name:CARRASCO
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1000
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93302-1000
Mailing Address - Country:US
Mailing Address - Phone:661-868-6817
Mailing Address - Fax:661-868-1428
Practice Address - Street 1:1600 E BELLE TER
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93307-3871
Practice Address - Country:US
Practice Address - Phone:661-635-2950
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-08
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF77870106H00000X
CALMFT102699106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist