Provider Demographics
NPI:1588164701
Name:IBARRA, YISELLE M
Entity type:Individual
Prefix:
First Name:YISELLE
Middle Name:M
Last Name:IBARRA
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 1:13205 HAYSTACK CT
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33579-9126
Mailing Address - Country:US
Mailing Address - Phone:813-453-4998
Mailing Address - Fax:
Practice Address - Street 1:1150 S SEMORAN BLVD STE A
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32807-1424
Practice Address - Country:US
Practice Address - Phone:407-704-7811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2020-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL9557687223Medicaid