Provider Demographics
NPI:1689980872
Name:IGNISABAN, PAMELA DAUZ-DE VIVAR
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:DAUZ-DE VIVAR
Last Name:IGNISABAN
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 1:19401 S VERMONT AVE STE A200
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-4418
Mailing Address - Country:US
Mailing Address - Phone:310-323-6887
Mailing Address - Fax:310-436-8285
Practice Address - Street 1:19401 S VERMONT AVE STE A200
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-4418
Practice Address - Country:US
Practice Address - Phone:310-323-6887
Practice Address - Fax:310-436-8285
Is Sole Proprietor?:No
Enumeration Date:2010-08-25
Last Update Date:2015-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
34940101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health