Provider Demographics
NPI:1669875647
Name:IBANEZ-BISSEN, DELIA
Entity type:Individual
Prefix:
First Name:DELIA
Middle Name:
Last Name:IBANEZ-BISSEN
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 1:19315 FM 2252 STE 136
Mailing Address - Street 2:
Mailing Address - City:GARDEN RIDGE
Mailing Address - State:TX
Mailing Address - Zip Code:78266-2556
Mailing Address - Country:US
Mailing Address - Phone:210-880-5038
Mailing Address - Fax:
Practice Address - Street 1:19315 FM 2252 STE 136
Practice Address - Street 2:
Practice Address - City:GARDEN RIDGE
Practice Address - State:TX
Practice Address - Zip Code:78266-2556
Practice Address - Country:US
Practice Address - Phone:210-880-5038
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-03
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX69698101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional