Provider Demographics
NPI:1366844391
Name:JOPHRYN-AVILA, PAMELA L
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:L
Last Name:JOPHRYN-AVILA
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 1:44554 BENALD ST
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-3438
Mailing Address - Country:US
Mailing Address - Phone:562-212-6473
Mailing Address - Fax:
Practice Address - Street 1:16360 ROSCOE BLVD FL 2
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-1219
Practice Address - Country:US
Practice Address - Phone:818-901-4830
Practice Address - Fax:818-901-8985
Is Sole Proprietor?:No
Enumeration Date:2014-09-22
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8919225400000X
CA8219101YA0400X
CA00727993171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No171M00000XOther Service ProvidersCase Manager/Care Coordinator