Provider Demographics
NPI:1033879135
Name:ALONZO, MARVIN ANDRES
Entity Type:Individual
Prefix:
First Name:MARVIN
Middle Name:ANDRES
Last Name:ALONZO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1576 CRUSADO LN # 317
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1514
Mailing Address - Country:US
Mailing Address - Phone:323-914-0679
Mailing Address - Fax:
Practice Address - Street 1:1050 LAKES DR STE 225
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91790-2910
Practice Address - Country:US
Practice Address - Phone:626-940-5180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-30
Last Update Date:2021-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA82-1922692OtherMEDICAL