Provider Demographics
NPI:1740394386
Name:IBANEZ, BERENICE (PHD)
Entity Type:Individual
Prefix:DR
First Name:BERENICE
Middle Name:
Last Name:IBANEZ
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4004 BEYER BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-2007
Mailing Address - Country:US
Mailing Address - Phone:619-428-5561
Mailing Address - Fax:619-205-1979
Practice Address - Street 1:4004 BEYER BLVD
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-2007
Practice Address - Country:US
Practice Address - Phone:619-428-5561
Practice Address - Fax:619-205-1979
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-19
Last Update Date:2012-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY22080103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist