Provider Demographics
NPI:1871798371
Name:YBARRA, PHILLIP F (C053610518)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:F
Last Name:YBARRA
Suffix:
Gender:M
Credentials:C053610518
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2020 IOWA AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-7428
Mailing Address - Country:US
Mailing Address - Phone:951-384-4699
Mailing Address - Fax:951-384-4750
Practice Address - Street 1:31764 CASINO DRIVE-300
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-7428
Practice Address - Country:US
Practice Address - Phone:951-471-4645
Practice Address - Fax:951-471-4687
Is Sole Proprietor?:No
Enumeration Date:2007-06-15
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC053610518101YA0400X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4386OtherSIMON STAFF NUMBER