Provider Demographics
NPI:1477012565
Name:LONGORIA, BERLEN
Entity Type:Individual
Prefix:
First Name:BERLEN
Middle Name:
Last Name:LONGORIA
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 1:14502 LOCH NEVIS AVE
Mailing Address - Street 2:
Mailing Address - City:NORWALK
Mailing Address - State:CA
Mailing Address - Zip Code:90650-5145
Mailing Address - Country:US
Mailing Address - Phone:562-417-0398
Mailing Address - Fax:
Practice Address - Street 1:3230 E IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-6721
Practice Address - Country:US
Practice Address - Phone:657-444-9002
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-18
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
106S00000XOtherBEHAVIOR TECHNICIAN