Healthcare Provider Details

I. General information

NPI: 1235635020
Provider Name (Legal Business Name): ALISSA CHARVONIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/02/2018
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11234 ANDERSON ST
LOMA LINDA CA
92350-1716
US

IV. Provider business mailing address

11175 CAMPUS ST # A1120
LOMA LINDA CA
92350-1700
US

V. Phone/Fax

Practice location:
  • Phone: 909-651-1899
  • Fax: 909-651-1770
Mailing address:
  • Phone: 909-558-8626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number35989
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: