Basic Information
| Provider Information | |||||||||
| NPI: | 1154677565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALVAREZ | ||||||||
| FirstName: | IRIS | ||||||||
| MiddleName: | JOANNE | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | B.A., BCABA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 15643 SHERMAN WAY STE 220 | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914064174 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8182327940 | ||||||||
| FaxNumber: | 8187829985 | ||||||||
| Practice Location | |||||||||
| Address1: | 5554 RESEDA BLVD STE 203 | ||||||||
| Address2: | |||||||||
| City: | TARZANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913566212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187055522 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2012 | ||||||||
| LastUpdateDate: | 05/03/2018 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 0-11-4117 | CA | N | Behavioral Health & Social Service Providers | Behavioral Analyst | 103K00000X | 1-14-16232 | CA | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
ID Information
| ID | Type | State | Issuer | Description | 1-14-16232 | 01 | CA | BCBA CERTIFICATE NUMBER | OTHER |