Provider Demographics
NPI:1659763282
Name:ICABALCETA, BERMAN IVAN JR
Entity Type:Individual
Prefix:MR
First Name:BERMAN
Middle Name:IVAN
Last Name:ICABALCETA
Suffix:JR
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 1:301 GRAND AVE
Mailing Address - Street 2:SUITE 301
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-3606
Mailing Address - Country:US
Mailing Address - Phone:650-244-0305
Mailing Address - Fax:650-244-1447
Practice Address - Street 1:1001 SNEATH LN STE 307
Practice Address - Street 2:
Practice Address - City:SAN BRUNO
Practice Address - State:CA
Practice Address - Zip Code:94066
Practice Address - Country:US
Practice Address - Phone:650-244-0305
Practice Address - Fax:650-244-1447
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-18
Last Update Date:2019-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA38472OtherTHE LATINO COMMISSION ADMINISTRATION