Provider Demographics
NPI:1376399253
Name:IBARRA DAVILA, MALLYTZA
Entity type:Individual
Prefix:
First Name:MALLYTZA
Middle Name:
Last Name:IBARRA DAVILA
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 1:26 IFFLEY RD
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-2307
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:39A INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-4868
Practice Address - Country:US
Practice Address - Phone:508-534-8048
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-30
Last Update Date:2024-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health