Provider Demographics
NPI:1194174631
Name:IBARZABAL, ILEANA
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:IBARZABAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2775 W 52ND ST APT 409
Mailing Address - Street 2:
Mailing Address - City:HIALEAH
Mailing Address - State:FL
Mailing Address - Zip Code:33016-4079
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5040 NW 7TH ST STE 685
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33126
Practice Address - Country:US
Practice Address - Phone:786-580-3737
Practice Address - Fax:786-580-3737
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-06
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1617779106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician