Provider Demographics
NPI:1619731114
Name:CERVANTES, JOSEPH MICHAEL
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:MICHAEL
Last Name:CERVANTES
Suffix:
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:PO BOX 626
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92856-6626
Mailing Address - Country:US
Mailing Address - Phone:714-744-9754
Mailing Address - Fax:
Practice Address - Street 1:1110 E CHAPMAN AVE STE 202
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92866-2139
Practice Address - Country:US
Practice Address - Phone:714-744-9754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-06
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY5963103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist