Healthcare Provider Details

I. General information

NPI: 1265599468
Provider Name (Legal Business Name): SELENE TLAXCALA M.S.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SELENE TLAXCALA-CABRERA M.S.

II. Dates (important events)

Enumeration Date: 01/03/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6301 BEACH BLVD #245
BUENA PARK CA
90621-2840
US

IV. Provider business mailing address

2008 DEERPARK DR APT. #205
FULLERTON CA
92831-1589
US

V. Phone/Fax

Practice location:
  • Phone: 714-736-0231
  • Fax: 714-736-0895
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License NumberIMF 38861
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: