Provider Demographics
NPI:1881465987
Name:PINA, IBIS
Entity type:Individual
Prefix:
First Name:IBIS
Middle Name:
Last Name:PINA
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 1:13524 DEL GADO RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-9705
Mailing Address - Country:US
Mailing Address - Phone:760-910-8316
Mailing Address - Fax:
Practice Address - Street 1:1274 CENTER COURT DR STE 211
Practice Address - Street 2:
Practice Address - City:COVINA
Practice Address - State:CA
Practice Address - Zip Code:91724-3668
Practice Address - Country:US
Practice Address - Phone:626-339-4999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-09
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst