Provider Demographics
NPI:1962993501
Name:IBARRA, EDITH (RBT-17-42921)
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:IBARRA
Suffix:
Gender:F
Credentials:RBT-17-42921
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1683 FIDDYMENT DR
Mailing Address - Street 2:
Mailing Address - City:ROMEOVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60446-5157
Mailing Address - Country:US
Mailing Address - Phone:815-919-7309
Mailing Address - Fax:
Practice Address - Street 1:1683 FIDDYMENT DR
Practice Address - Street 2:
Practice Address - City:ROMEOVILLE
Practice Address - State:IL
Practice Address - Zip Code:60446-5157
Practice Address - Country:US
Practice Address - Phone:815-919-7309
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-18
Last Update Date:2018-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILRBT-17-42921106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician