Healthcare Provider Details

I. General information

NPI: 1285932541
Provider Name (Legal Business Name): MARIA CLEMENTINA AVALOS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/09/2011
Last Update Date: 04/19/2021
Certification Date: 04/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11263 CHIVERS AVE
PACOIMA CA
91331-1518
US

IV. Provider business mailing address

2550 E FOOTHILL BLVD
PASADENA CA
91107-3406
US

V. Phone/Fax

Practice location:
  • Phone: 818-585-5679
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number190096026
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: