Healthcare Provider Details

I. General information

NPI: 1710849468
Provider Name (Legal Business Name): COMMUNITY EVOLUTION ACQUISITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/01/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1767 VALLECITO DR
SAN PEDRO CA
90732-4245
US

IV. Provider business mailing address

1767 VALLECITO DR
SAN PEDRO CA
90732-4245
US

V. Phone/Fax

Practice location:
  • Phone: 424-503-3336
  • Fax:
Mailing address:
  • Phone: 424-503-3336
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State

VIII. Authorized Official

Name: TIA LOPEZ
Title or Position: CEO
Credential: BACHELORS SOCIAL W
Phone: 424-503-3336