Provider Demographics
NPI:1205513967
Name:IBARRA, PANFILO
Entity type:Individual
Prefix:
First Name:PANFILO
Middle Name:
Last Name:IBARRA
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:PO BOX 1666
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667-1666
Mailing Address - Country:US
Mailing Address - Phone:530-626-9240
Mailing Address - Fax:
Practice Address - Street 1:838 BEACH CT
Practice Address - Street 2:
Practice Address - City:COLOMA
Practice Address - State:CA
Practice Address - Zip Code:95667-4625
Practice Address - Country:US
Practice Address - Phone:530-626-7252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-03
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1465420422101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)