Provider Demographics
NPI:1609820398
Name:MCGIVERN, IDALIA E (PHD)
Entity Type:Individual
Prefix:DR
First Name:IDALIA
Middle Name:E
Last Name:MCGIVERN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:IDALIA
Other - Middle Name:E
Other - Last Name:CANEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:9340 FUERTE DR
Mailing Address - Street 2:SUITE 300
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91941-4164
Mailing Address - Country:US
Mailing Address - Phone:619-303-0826
Mailing Address - Fax:619-315-0454
Practice Address - Street 1:9340 FUERTE DR
Practice Address - Street 2:SUITE 300
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-4164
Practice Address - Country:US
Practice Address - Phone:619-303-0826
Practice Address - Fax:619-315-0454
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY18250103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical