Healthcare Provider Details

I. General information

NPI: 1346778370
Provider Name (Legal Business Name): TANIA GUADALUPE GARCIA AVALOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/04/2017
Last Update Date: 06/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 W RAMSEY ST
BANNING CA
92220-4477
US

IV. Provider business mailing address

20897 VERTA ST
PERRIS CA
92570-7684
US

V. Phone/Fax

Practice location:
  • Phone: 951-849-7142
  • Fax:
Mailing address:
  • Phone: 951-490-5078
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: