Provider Demographics
NPI:1548150964
Name:CAMACHO, IVENN GAMALIEL
Entity type:Individual
Prefix:
First Name:IVENN
Middle Name:GAMALIEL
Last Name:CAMACHO
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 1:930 S MOUNT VERNON AVE STE 90
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-3928
Mailing Address - Country:US
Mailing Address - Phone:909-285-7936
Mailing Address - Fax:
Practice Address - Street 1:930 S MOUNT VERNON AVE, 90
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-3572
Practice Address - Country:US
Practice Address - Phone:951-565-7508
Practice Address - Fax:951-565-7508
Is Sole Proprietor?:No
Enumeration Date:2025-07-07
Last Update Date:2025-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician