Provider Demographics
NPI:1265807051
Name:SIMPLICE-COLIN, IVENA
Entity type:Individual
Prefix:
First Name:IVENA
Middle Name:
Last Name:SIMPLICE-COLIN
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 1:2380 SALVIO ST STE 200
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:CA
Mailing Address - Zip Code:94520-2193
Mailing Address - Country:US
Mailing Address - Phone:925-602-1750
Mailing Address - Fax:
Practice Address - Street 1:2380 SALVIO ST STE 200
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:CA
Practice Address - Zip Code:94520
Practice Address - Country:US
Practice Address - Phone:925-602-1750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-06
Last Update Date:2019-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMX-094141041S0200X
CAASW832311041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No1041S0200XBehavioral Health & Social Service ProvidersSocial WorkerSchool
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAASW83231Medicaid
NMX-09414Medicaid