Provider Demographics
NPI:1205407152
Name:SALAZAR, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:SALAZAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3201 CHERRY RIDGE DR STE 205B
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-4832
Mailing Address - Country:US
Mailing Address - Phone:210-685-2266
Mailing Address - Fax:
Practice Address - Street 1:3201 CHERRY RIDGE DR STE 205B
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-4832
Practice Address - Country:US
Practice Address - Phone:210-685-2266
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-01
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician