Healthcare Provider Details

I. General information

NPI: 1700360815
Provider Name (Legal Business Name): ALYSSA JACQUELINE IMPERIAL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2018
Last Update Date: 02/11/2020
Certification Date: 02/11/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

867 N FAIR OAKS AVE
PASADENA CA
91103-3050
US

IV. Provider business mailing address

PO BOX 1043
GLENDORA CA
91740-1043
US

V. Phone/Fax

Practice location:
  • Phone: 626-993-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberASW92300
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: