Provider Demographics
NPI:1184997686
Name:IBIS, PATRICIA GAIL
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:GAIL
Last Name:IBIS
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 1:4322 MATILIJA AVE APT 12
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423-3677
Mailing Address - Country:US
Mailing Address - Phone:310-498-1963
Mailing Address - Fax:
Practice Address - Street 1:17490 N 93RD ST
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-6323
Practice Address - Country:US
Practice Address - Phone:480-630-3749
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ89002251G0304X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251G0304XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGeriatrics