Provider Demographics
NPI:1710256060
Name:IBARRA, SALLY (SRCM)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:
Last Name:IBARRA
Suffix:
Gender:F
Credentials:SRCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23502 LYONS AVE STE 304A
Mailing Address - Street 2:
Mailing Address - City:NEWHALL
Mailing Address - State:CA
Mailing Address - Zip Code:91321-2538
Mailing Address - Country:US
Mailing Address - Phone:661-286-2562
Mailing Address - Fax:661-222-7709
Practice Address - Street 1:23502 LYONS AVE STE 304A
Practice Address - Street 2:
Practice Address - City:NEWHALL
Practice Address - State:CA
Practice Address - Zip Code:91321-2538
Practice Address - Country:US
Practice Address - Phone:661-286-2562
Practice Address - Fax:661-222-7709
Is Sole Proprietor?:No
Enumeration Date:2011-12-15
Last Update Date:2013-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner