Provider Demographics
NPI:1609514793
Name:MENJIVAR, IVONNE E (NONE)
Entity Type:Individual
Prefix:
First Name:IVONNE
Middle Name:E
Last Name:MENJIVAR
Suffix:
Gender:F
Credentials:NONE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:626 W. LANCASTER BLVD. #52
Mailing Address - Street 2:
Mailing Address - City:PALMDALE
Mailing Address - State:CA
Mailing Address - Zip Code:93534
Mailing Address - Country:US
Mailing Address - Phone:661-258-3211
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:626 W. LANCASTER BLVD. #52
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93534
Practice Address - Country:US
Practice Address - Phone:661-258-3211
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2022-05-26
Last Update Date:2022-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician