Provider Demographics
NPI:1639236912
Name:AREVALO, LAURA LYNNE (MFT)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LYNNE
Last Name:AREVALO
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4224 FOWLER LN STE 201
Mailing Address - Street 2:
Mailing Address - City:DIAMOND SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:95619-9775
Mailing Address - Country:US
Mailing Address - Phone:530-363-8896
Mailing Address - Fax:530-677-7317
Practice Address - Street 1:4224 FOWLER LN STE 201
Practice Address - Street 2:
Practice Address - City:DIAMOND SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:95619-9775
Practice Address - Country:US
Practice Address - Phone:530-363-8896
Practice Address - Fax:530-677-7317
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-03
Last Update Date:2018-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC39068106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist