Provider Demographics
NPI:1659934578
Name:AVALOS, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:AVALOS
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 1:2091 BUSINESS CENTER DR STE 150
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92612-1167
Mailing Address - Country:US
Mailing Address - Phone:949-250-1101
Mailing Address - Fax:949-250-1103
Practice Address - Street 1:2091 BUSINESS CENTER DR STE 150
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92612-1167
Practice Address - Country:US
Practice Address - Phone:949-250-1101
Practice Address - Fax:949-250-1103
Is Sole Proprietor?:No
Enumeration Date:2019-04-16
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst