Provider Demographics
NPI:1710585450
Name:PALACIOS, DINORA
Entity Type:Individual
Prefix:
First Name:DINORA
Middle Name:
Last Name:PALACIOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8117 WYNNE AVE
Mailing Address - Street 2:
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-1338
Mailing Address - Country:US
Mailing Address - Phone:818-270-4286
Mailing Address - Fax:
Practice Address - Street 1:7120 HAYVENHURST AVE STE 322
Practice Address - Street 2:
Practice Address - City:VAN NUYS
Practice Address - State:CA
Practice Address - Zip Code:91406-3813
Practice Address - Country:US
Practice Address - Phone:800-930-5773
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior AnalystGroup - Multi-Specialty