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General NPI Number Information
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NPI Number | 1730581760
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Entity Type | Organization
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Legal Business Name | AVANT-GARDE COMMUNITY COUNSELING CENTER
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Dates
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Enumeration Date | 09/22/2014
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Last Update Date | 09/23/2014
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Provider Practice Location Address
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Address Line | 1655 E 6TH ST STE A5A
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City | CORONA
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State | CA
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Zip | 92879-1719
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Country | US
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Telephone | 951-735-5300
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Fax | 951-735-9335
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Provider Business Mailing Address
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Address Line | 1655 E 6TH ST STE 117A5A
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City | CORONA
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State | CA
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Zip | 92879-1732
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Country | US
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Telephone | 951-735-5300
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Fax | 951-735-9335
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Authorized Official
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Title or Position | CEO
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Name | GREGORY ESTRAVIT
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Credential |
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Telephone | 951-735-5300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YM0800X
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Taxonomy Name | Mental Health Counselor
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License Number | MFC27861
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License Number State | CA
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