Provider Demographics
NPI:1558043547
Name:IBARRA, DESTINY KAYLA
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:KAYLA
Last Name:IBARRA
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 1:770 WESLEY ST
Mailing Address - Street 2:
Mailing Address - City:BANNING
Mailing Address - State:CA
Mailing Address - Zip Code:92220-6162
Mailing Address - Country:US
Mailing Address - Phone:951-743-4622
Mailing Address - Fax:
Practice Address - Street 1:770 WESLEY ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-6162
Practice Address - Country:US
Practice Address - Phone:951-743-4622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-01
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician