Provider Demographics
NPI:1588033005
Name:MACIAS, IVAN
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:MACIAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1060 W SIERRA AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-2063
Mailing Address - Country:US
Mailing Address - Phone:559-437-1111
Mailing Address - Fax:
Practice Address - Street 1:1060 W SIERRA AVE STE 104
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-2063
Practice Address - Country:US
Practice Address - Phone:559-437-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-15
Last Update Date:2023-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA139733106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist