Healthcare Provider Details

I. General information

NPI: 1366844391
Provider Name (Legal Business Name): PAMELA L. JOPHRYN-AVILA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2014
Last Update Date: 11/20/2024
Certification Date: 11/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2260 E PALMDALE BLVD STE J
PALMDALE CA
93550-4952
US

IV. Provider business mailing address

44554 BENALD ST
LANCASTER CA
93535-3438
US

V. Phone/Fax

Practice location:
  • Phone: 661-575-8000
  • Fax:
Mailing address:
  • Phone: 562-212-6473
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number00727993
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number8919
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW125474
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number8219
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: