Provider Demographics
NPI:1700409398
Name:LERVOLD, EMMA
Entity Type:Individual
Prefix:
First Name:EMMA
Middle Name:
Last Name:LERVOLD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:EMMA
Other - Middle Name:LERVOLD
Other - Last Name:HENRY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2628 CALLE ONICE
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-3906
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12235 BEACH BLVD
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3939
Practice Address - Country:US
Practice Address - Phone:714-202-0118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-18
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician