Provider Demographics
NPI:1073062766
Name:ANGUIANO, EILEEN RENE (RADT-1)
Entity Type:Individual
Prefix:MS
First Name:EILEEN
Middle Name:RENE
Last Name:ANGUIANO
Suffix:
Gender:F
Credentials:RADT-1
Other - Prefix:MS
Other - First Name:EILEEN
Other - Middle Name:RENE
Other - Last Name:ANGUIANO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:590 W 8TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731
Mailing Address - Country:US
Mailing Address - Phone:310-831-2358
Mailing Address - Fax:
Practice Address - Street 1:1318 N AVALON BLVD # A
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:CA
Practice Address - Zip Code:90744-2639
Practice Address - Country:US
Practice Address - Phone:310-495-2710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-23
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR4001214101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)