Provider Demographics
NPI:1235657750
Name:TELYAGOVA, PAOLA KARINA (MFTI)
Entity Type:Individual
Prefix:
First Name:PAOLA
Middle Name:KARINA
Last Name:TELYAGOVA
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:PAOLA
Other - Middle Name:KARINA
Other - Last Name:CARDONA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MFTI
Mailing Address - Street 1:26888 DAY BREAK DR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883-6232
Mailing Address - Country:US
Mailing Address - Phone:818-203-8855
Mailing Address - Fax:
Practice Address - Street 1:11498 PIERCE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3357
Practice Address - Country:US
Practice Address - Phone:951-354-6294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-05
Last Update Date:2017-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF85968106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2131100830501Medicaid