Basic Information
| Provider Information | |||||||||
| NPI: | 1114401726 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | IBARRA | ||||||||
| FirstName: | PAUL | ||||||||
| MiddleName: | NICK | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9265 SHORE RD APT 4E | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112096591 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3475241324 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 800 POLY PL | ||||||||
| Address2: | |||||||||
| City: | BROOKLYN | ||||||||
| State: | NY | ||||||||
| PostalCode: | 112097104 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7188366600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2018 | ||||||||
| LastUpdateDate: | 09/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 0291867 | NY | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.