Provider Demographics
NPI:1760594782
Name:IBSEN, RALPH C (MSW)
Entity Type:Individual
Prefix:
First Name:RALPH
Middle Name:C
Last Name:IBSEN
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2450 E SHOW LOW LAKE RD
Mailing Address - Street 2:SUITE 3A
Mailing Address - City:SHOW LOW
Mailing Address - State:AZ
Mailing Address - Zip Code:85901-7953
Mailing Address - Country:US
Mailing Address - Phone:928-532-1069
Mailing Address - Fax:602-212-2005
Practice Address - Street 1:2450 E SHOW LOW LAKE RD
Practice Address - Street 2:SUITE 3A
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7953
Practice Address - Country:US
Practice Address - Phone:928-532-1069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-02631041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical