Healthcare Provider Details

I. General information

NPI: 1831874155
Provider Name (Legal Business Name): AVA RAIE GEVISSER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2023
Last Update Date: 06/15/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12062 VALLEY VIEW ST
GARDEN GROVE CA
92845-1737
US

IV. Provider business mailing address

11522 MARTHA ANN DR
LOS ALAMITOS CA
90720-4004
US

V. Phone/Fax

Practice location:
  • Phone: 562-356-8600
  • Fax:
Mailing address:
  • Phone: 818-521-3127
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: