Provider Demographics
NPI:1740903293
Name:ICON BEHAVIORAL AND MENTAL HEALTHCARE INC
Entity type:Organization
Organization Name:ICON BEHAVIORAL AND MENTAL HEALTHCARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:
Authorized Official - Last Name:IVOKO
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:909-351-4441
Mailing Address - Street 1:9087 ARROW RTE STE 265
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4487
Mailing Address - Country:US
Mailing Address - Phone:909-351-4441
Mailing Address - Fax:909-351-4411
Practice Address - Street 1:9087 ARROW RTE STE 265
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4487
Practice Address - Country:US
Practice Address - Phone:909-351-4441
Practice Address - Fax:909-351-4411
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-09-20
Last Update Date:2022-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty