Provider Demographics
NPI:1063632230
Name:IBRAHIM, DARLENE
Entity Type:Individual
Prefix:
First Name:DARLENE
Middle Name:
Last Name:IBRAHIM
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:PO BOX 468
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91305-0468
Mailing Address - Country:US
Mailing Address - Phone:818-668-4834
Mailing Address - Fax:
Practice Address - Street 1:8714 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:NORTH HILLS
Practice Address - State:CA
Practice Address - Zip Code:91343-5112
Practice Address - Country:US
Practice Address - Phone:818-830-0999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-27
Last Update Date:2018-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6625101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7086OtherPROVIDER NUMBER