Provider Demographics
NPI:1619505088
Name:CERVANTES, EDGAR J (LMFT)
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:J
Last Name:CERVANTES
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9825 MAGNOLIA AVE STE B
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-3565
Mailing Address - Country:US
Mailing Address - Phone:951-509-2499
Mailing Address - Fax:
Practice Address - Street 1:6800 INDIANA AVE STE 130
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-4266
Practice Address - Country:US
Practice Address - Phone:323-273-6886
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-31
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA109185106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist