Provider Demographics
NPI:1275995458
Name:PODRESOV, AUDREY
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:
Last Name:PODRESOV
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1720 TERMINO AVE
Mailing Address - Street 2:BEHAVIORAL HEALTH UNIT
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90804-2104
Mailing Address - Country:US
Mailing Address - Phone:562-480-1087
Mailing Address - Fax:
Practice Address - Street 1:1720 TERMINO AVE
Practice Address - Street 2:BEHAVIORAL HEALTH UNIT
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-2104
Practice Address - Country:US
Practice Address - Phone:562-498-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-25
Last Update Date:2016-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN489283103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst