Healthcare Provider Details

I. General information

NPI: 1992179246
Provider Name (Legal Business Name): ITZEL ANAHI BAHENA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2015
Last Update Date: 11/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 E MAIN ST FL 3
SANTA PAULA CA
93060-2748
US

IV. Provider business mailing address

725 E MAIN ST FL 3
SANTA PAULA CA
93060-2748
US

V. Phone/Fax

Practice location:
  • Phone: 805-933-8440
  • Fax: 805-933-0057
Mailing address:
  • Phone: 805-933-8440
  • Fax: 805-933-0057

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: