Provider Demographics
NPI:1538203815
Name:IBERG, VIRGIL GLENN
Entity type:Individual
Prefix:MR
First Name:VIRGIL
Middle Name:GLENN
Last Name:IBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1310 N UNIVERSITY ST
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-2643
Mailing Address - Country:US
Mailing Address - Phone:909-792-8810
Mailing Address - Fax:
Practice Address - Street 1:3768 10TH ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-3621
Practice Address - Country:US
Practice Address - Phone:951-276-3071
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANONE101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)