Provider Demographics
NPI:1164558607
Name:IVAN, DARIA MONICA (MSPT, COMT)
Entity Type:Individual
Prefix:
First Name:DARIA
Middle Name:MONICA
Last Name:IVAN
Suffix:
Gender:F
Credentials:MSPT, COMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2515 CARLMONT DR APT 19
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-3261
Mailing Address - Country:US
Mailing Address - Phone:703-489-4496
Mailing Address - Fax:
Practice Address - Street 1:540 RALSTON AVE STE B
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-2866
Practice Address - Country:US
Practice Address - Phone:303-971-0500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0018272225100000X
VA2305203988225100000X
CA32755225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist