Provider Demographics
NPI:1093274136
Name:TAPIA HERNANDEZ, IVAN
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:TAPIA HERNANDEZ
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 1:130 SE 105TH AVE APT C1
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2955
Mailing Address - Country:US
Mailing Address - Phone:707-849-4576
Mailing Address - Fax:
Practice Address - Street 1:130 SE 105TH AVE APT C1
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2955
Practice Address - Country:US
Practice Address - Phone:707-849-4576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2025-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician