Provider Demographics
NPI:1649774282
Name:CASABIANCA, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:CASABIANCA
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 1:505 N EUCLID ST # 300
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92801-5506
Mailing Address - Country:US
Mailing Address - Phone:714-871-5646
Mailing Address - Fax:
Practice Address - Street 1:505 N EUCLID ST # 300
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92801-5506
Practice Address - Country:US
Practice Address - Phone:714-871-5646
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2018-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health