Provider Demographics
NPI:1346830189
Name:MOBRI, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:MOBRI
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 1:10350 SW 220TH ST APT 142
Mailing Address - Street 2:
Mailing Address - City:CUTLER BAY
Mailing Address - State:FL
Mailing Address - Zip Code:33190-1502
Mailing Address - Country:US
Mailing Address - Phone:786-805-5334
Mailing Address - Fax:
Practice Address - Street 1:10350 SW 220TH ST APT 142
Practice Address - Street 2:
Practice Address - City:CUTLER BAY
Practice Address - State:FL
Practice Address - Zip Code:33190-1502
Practice Address - Country:US
Practice Address - Phone:786-971-8605
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-26
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL118658106S00000X
FLRBT-20-118658106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL109069800Medicaid