Provider Demographics
NPI:1518246610
Name:IBRAHIM, NOVINE Y
Entity Type:Individual
Prefix:MS
First Name:NOVINE
Middle Name:Y
Last Name:IBRAHIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1218 S ALTA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-4061
Mailing Address - Country:US
Mailing Address - Phone:626-301-9005
Mailing Address - Fax:
Practice Address - Street 1:1218 S ALTA VISTA AVE
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-4061
Practice Address - Country:US
Practice Address - Phone:626-301-9005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-08
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4797225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4797Medicaid
CA4797Medicaid