Provider Demographics
NPI:1164082160
Name:PALACIOS, ROBERTO C
Entity Type:Individual
Prefix:
First Name:ROBERTO
Middle Name:C
Last Name:PALACIOS
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 1:6412 BOLLENBACHER DR
Mailing Address - Street 2:
Mailing Address - City:PICO RIVERA
Mailing Address - State:CA
Mailing Address - Zip Code:90660-3445
Mailing Address - Country:US
Mailing Address - Phone:717-730-5399
Mailing Address - Fax:714-730-3505
Practice Address - Street 1:13682 YORBA ST
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-1831
Practice Address - Country:US
Practice Address - Phone:714-730-5399
Practice Address - Fax:714-730-3505
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-20
Last Update Date:2019-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health