Healthcare Provider Details

I. General information

NPI: 1356486054
Provider Name (Legal Business Name): GENOVEVA MARIA AVALOS-MIRELES MSW LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/20/2007
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9628 CAMPO RD SUITE T
SPRING VALLEY CA
91977-1245
US

IV. Provider business mailing address

PO BOX 2045
SPRING VALLEY CA
91979-2045
US

V. Phone/Fax

Practice location:
  • Phone: 619-818-6533
  • Fax: 187-782-5946
Mailing address:
  • Phone: 619-818-6533
  • Fax: 187-782-5946

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLCSW 21116
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: