Provider Demographics
NPI:1477108314
Name:AREVALO, VANESSA
Entity Type:Individual
Prefix:
First Name:VANESSA
Middle Name:
Last Name:AREVALO
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 1:1123 W SANDISON ST
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:CA
Mailing Address - Zip Code:90744-1944
Mailing Address - Country:US
Mailing Address - Phone:310-707-3934
Mailing Address - Fax:
Practice Address - Street 1:2248 OBISPO AVE STE 202
Practice Address - Street 2:
Practice Address - City:SIGNAL HILL
Practice Address - State:CA
Practice Address - Zip Code:90755-4026
Practice Address - Country:US
Practice Address - Phone:213-550-2634
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-07
Last Update Date:2020-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator