MEDICARE: ENTRE AMIGOS HUMAN SERVICES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103TC0700X	Clinical Psychologist	PSY 19431	CA
2	106H00000X	Marriage & Family Therapist	IMF 49184	CA
3	103TC0700X	Clinical Psychologist	PSY 14867	CA

General Provider Information

NPI Number	:	1891901385
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ENTRE AMIGOS HUMAN SERVICES, LLC

Provider Business Mailing Address
First Line	:	11001 VALLEY MALL STE 204
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91731-2620
Country	:	US
Telephone Number	:	626-582-8912
Fax Number	:	626-582-8895

Provider Business Practice Location Address
First Line	:	11001 VALLEY MALL STE 204
Second Line	:
City	:	EL MONTE
State	:	CA
Zip	:	91731-2620
Country	:	US
Telephone Number	:	626-582-8912
Fax Number	:	626-582-8895

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MR. EDUARDO LUIS LOPEZ-NAVARRO
Credential	:	MFT INTERN
Telephone Number	:	626-582-8912

Provider Enumeration Date	:	05/14/2007
Last Update Date	:	06/07/2011

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