Provider Demographics
NPI:1578513073
Name:AREVALO, LUIS ERNESTO (PHD)
Entity Type:Individual
Prefix:DR
First Name:LUIS
Middle Name:ERNESTO
Last Name:AREVALO
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2712 5TH ST
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-5027
Mailing Address - Country:US
Mailing Address - Phone:909-596-7118
Mailing Address - Fax:909-596-2548
Practice Address - Street 1:1745 W ORANGEWOOD AVE STE 101
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-2041
Practice Address - Country:US
Practice Address - Phone:714-639-1933
Practice Address - Fax:909-596-2548
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2014-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY10821103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY108210Medicaid
CAPSY108210Medicaid
CALACP10821Medicare ID - Type Unspecified