Healthcare Provider Details

I. General information

NPI: 1659757805
Provider Name (Legal Business Name): BRANDON RUVALCABA LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2015
Last Update Date: 03/16/2023
Certification Date: 03/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1359 N GRAND AVE
COVINA CA
91724-1016
US

IV. Provider business mailing address

1359 N GRAND AVE
COVINA CA
91724-1016
US

V. Phone/Fax

Practice location:
  • Phone: 626-430-2853
  • Fax: 626-331-0035
Mailing address:
  • Phone: 626-430-2853
  • Fax: 626-331-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberASW91651
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number110770
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: