Provider Demographics
NPI:1801641550
Name:HYDER, IBTISAM SHIMUL
Entity type:Individual
Prefix:MS
First Name:IBTISAM
Middle Name:SHIMUL
Last Name:HYDER
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 1:301 N PRAIRIE AVE STE 510
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-4512
Mailing Address - Country:US
Mailing Address - Phone:747-222-6295
Mailing Address - Fax:
Practice Address - Street 1:301 N PRAIRIE AVE STE 510
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-4512
Practice Address - Country:US
Practice Address - Phone:747-222-6295
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-17
Last Update Date:2024-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA138089106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist