Provider Demographics
NPI:1730683988
Name:IBARRA DIAZ, WENDY RUBY
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:RUBY
Last Name:IBARRA DIAZ
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 1:330 9TH ST STE 8
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95901-5342
Mailing Address - Country:US
Mailing Address - Phone:916-676-0488
Mailing Address - Fax:
Practice Address - Street 1:10235 LARKIN RD SPC 4
Practice Address - Street 2:
Practice Address - City:LIVE OAK
Practice Address - State:CA
Practice Address - Zip Code:95953-2141
Practice Address - Country:US
Practice Address - Phone:408-913-0801
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-22
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician