Healthcare Provider Details

I. General information

NPI: 1811567258
Provider Name (Legal Business Name): ILIANA FAVILA-DE LA TRINIDAD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/28/2021
Last Update Date: 12/12/2025
Certification Date: 12/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1201 W LA VETA AVE
ORANGE CA
92868
US

IV. Provider business mailing address

1201 W LA VETA AVE
ORANGE CA
92868-4203
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-8481
  • Fax:
Mailing address:
  • Phone: 714-509-8481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY36057
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: