Provider Demographics
NPI:1447842224
Name:ONOFRE IBARRA, ELIAS
Entity type:Individual
Prefix:
First Name:ELIAS
Middle Name:
Last Name:ONOFRE IBARRA
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 1:11565 LAUREL CANYON BLVD UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SAN FERNANDO
Mailing Address - State:CA
Mailing Address - Zip Code:91340-4168
Mailing Address - Country:US
Mailing Address - Phone:818-361-5030
Mailing Address - Fax:
Practice Address - Street 1:1227 E LOS ANGELES AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93065-2871
Practice Address - Country:US
Practice Address - Phone:805-562-4080
Practice Address - Fax:805-579-6010
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CAAMFT123045106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner