Provider Demographics
NPI:1598528184
Name:ALFONSO, PAUL CHARLES JR
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:CHARLES
Last Name:ALFONSO
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40750 AVENIDA ARCADA
Mailing Address - Street 2:
Mailing Address - City:PALM DESERT
Mailing Address - State:CA
Mailing Address - Zip Code:92260-0384
Mailing Address - Country:US
Mailing Address - Phone:442-451-8147
Mailing Address - Fax:
Practice Address - Street 1:77824 WILDCAT DR
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92211-1134
Practice Address - Country:US
Practice Address - Phone:760-237-8070
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAF7142652106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician