Provider Demographics
NPI:1730670613
Name:CUASAY, IVAN KRISTOFLE
Entity Type:Individual
Prefix:
First Name:IVAN KRISTOFLE
Middle Name:
Last Name:CUASAY
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 1:5316 KUNGSTING WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-3517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1050 FULTON AVE STE 35
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-4272
Practice Address - Country:US
Practice Address - Phone:916-974-2599
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-25
Last Update Date:2018-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician