Provider Demographics
NPI:1821410069
Name:FARRIS, IVA
Entity Type:Individual
Prefix:
First Name:IVA
Middle Name:
Last Name:FARRIS
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 1:1682 SILVERWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:MANTECA
Mailing Address - State:CA
Mailing Address - Zip Code:95336-2827
Mailing Address - Country:US
Mailing Address - Phone:209-505-9536
Mailing Address - Fax:
Practice Address - Street 1:1682 SILVERWOOD AVE
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-2827
Practice Address - Country:US
Practice Address - Phone:209-505-9536
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-07
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-13-14508103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst