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General NPI Number Information
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NPI Number | 1528711280
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Entity Type | Individual
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Provider Name | IRVIN OMAR JUAREZ
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Gender | Male
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Dates
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Enumeration Date | 02/01/2022
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Last Update Date | 02/01/2022
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Provider Practice Location Address
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Address Line | 851 S MOUNT VERNON AVE STE 7A
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City | COLTON
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State | CA
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Zip | 92324-3926
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Country | US
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Telephone | 760-241-6044
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Fax |
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Provider Business Mailing Address
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Address Line | 15675 PAINE ST
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City | FONTANA
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State | CA
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Zip | 92336-8744
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Country | US
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Telephone | 909-279-5888
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101Y00000X
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Taxonomy Name | Counselor
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License Number | 130893
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 101YP2500X
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Taxonomy Name | Professional Counselor
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License Number | 130893
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License Number State | CA
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Taxonomy #3
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | 130893
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License Number State | CA
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Taxonomy #4
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Taxonomy Code | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | 130893
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License Number State | CA
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