Provider Demographics
NPI:1457680431
Name:DE AZEVEDO, AZUCENA MARISOL
Entity Type:Individual
Prefix:MRS
First Name:AZUCENA
Middle Name:MARISOL
Last Name:DE AZEVEDO
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 1:3492 AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-1306
Mailing Address - Country:US
Mailing Address - Phone:805-813-0177
Mailing Address - Fax:
Practice Address - Street 1:3492 AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-1306
Practice Address - Country:US
Practice Address - Phone:805-813-0177
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-21
Last Update Date:2020-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist