Provider Demographics
NPI:1174294920
Name:LEAL, IVAN PAUL (ACSW)
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:PAUL
Last Name:LEAL
Suffix:
Gender:M
Credentials:ACSW
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 5001
Mailing Address - Street 2:
Mailing Address - City:CALIPATRIA
Mailing Address - State:CA
Mailing Address - Zip Code:92233-5001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7018 BLAIR RD
Practice Address - Street 2:
Practice Address - City:CALIPATRIA
Practice Address - State:CA
Practice Address - Zip Code:92233-9633
Practice Address - Country:US
Practice Address - Phone:760-348-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-22
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1183601041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical