Provider Demographics
NPI:1104206317
Name:LLERA, DEBRA LYNN
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:LYNN
Last Name:LLERA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DEBRA
Other - Middle Name:LYNN
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27660 MERIDIAN STREET
Mailing Address - Street 2:
Mailing Address - City:HEMET
Mailing Address - State:CA
Mailing Address - Zip Code:92544
Mailing Address - Country:US
Mailing Address - Phone:951-691-0245
Mailing Address - Fax:
Practice Address - Street 1:14700 MANZANITA PARK RD
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:CA
Practice Address - Zip Code:92223
Practice Address - Country:US
Practice Address - Phone:951-845-3155
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-02
Last Update Date:2015-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80266106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA46-2851075Medicaid