Provider Demographics
NPI:1205209038
Name:IBANEZ, VIVIAN (MA, BCBA)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:IBANEZ
Suffix:
Gender:F
Credentials:MA, BCBA
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 100256
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32610-0256
Mailing Address - Country:US
Mailing Address - Phone:352-265-4357
Mailing Address - Fax:352-392-3614
Practice Address - Street 1:1015 NW 56TH TER
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32605-4481
Practice Address - Country:US
Practice Address - Phone:352-835-5520
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-02
Last Update Date:2019-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-15-19872103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022846900Medicaid