MEDICARE: MRS. HAYLIE J RENDON

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	101Y00000X	Counselor	00136	CA
2	106S00000X	Behavior Technician	11002	CA

General Provider Information

NPI Number	:	1992370076
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HAYLIE J RENDON

Provider Business Mailing Address
First Line	:	7226 SEPULVEDA BLVD
Second Line	:
City	:	VAN NUYS
State	:	CA
Zip	:	91405-2003
Country	:	US
Telephone Number	:	818-235-1414
Fax Number	:

Provider Business Practice Location Address
First Line	:	3838 CAMINO DEL RIO N STE 204
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92108-1741
Country	:	US
Telephone Number	:	619-880-4949
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/21/2021
Last Update Date	:	04/25/2022

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