Provider Demographics
NPI:1255054276
Name:IBEA, RAQUEL MALAPIT
Entity type:Individual
Prefix:
First Name:RAQUEL
Middle Name:MALAPIT
Last Name:IBEA
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:PO BOX 5070
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95205-0070
Mailing Address - Country:US
Mailing Address - Phone:209-870-8725
Mailing Address - Fax:
Practice Address - Street 1:1981 CHEROKEE RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95205-2720
Practice Address - Country:US
Practice Address - Phone:209-870-8725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-23
Last Update Date:2022-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13037101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA324500000XOtherNON PROFT
CA324500000XMedicaid