Provider Demographics
NPI:1265137004
Name:ALVAREZ, IVAN DEJESUS (SCHOOL PSYCHOLOGIST)
Entity type:Individual
Prefix:DR
First Name:IVAN
Middle Name:DEJESUS
Last Name:ALVAREZ
Suffix:
Gender:M
Credentials:SCHOOL PSYCHOLOGIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1931
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93438-1931
Mailing Address - Country:US
Mailing Address - Phone:805-293-1898
Mailing Address - Fax:
Practice Address - Street 1:425 W CENTRAL AVE STE 101A
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-2806
Practice Address - Country:US
Practice Address - Phone:805-741-7668
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-03
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA210009309103TS0200X
CA3516103TM1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities