Provider Demographics
NPI:1326606567
Name:IVANEZ, JOAQUIN ANTONIO (BA)
Entity Type:Individual
Prefix:
First Name:JOAQUIN
Middle Name:ANTONIO
Last Name:IVANEZ
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 SHERWIN ST
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77007-1033
Mailing Address - Country:US
Mailing Address - Phone:281-415-6825
Mailing Address - Fax:
Practice Address - Street 1:2101 CRAWFORD ST STE 208
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77002-8941
Practice Address - Country:US
Practice Address - Phone:253-854-5432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-03
Last Update Date:2019-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health