Provider Demographics
NPI:1316535685
Name:JAVIER, ALLYSON MEG CEREZO
Entity Type:Individual
Prefix:
First Name:ALLYSON MEG
Middle Name:CEREZO
Last Name:JAVIER
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 1:375 S 9TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95112-3668
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1171 HOMESTEAD RD
Practice Address - Street 2:
Practice Address - City:SANTA CLARA
Practice Address - State:CA
Practice Address - Zip Code:95050-5478
Practice Address - Country:US
Practice Address - Phone:877-910-6538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician