Provider Demographics
NPI:1891557385
Name:TAVAREZ, JULISSA MARIE GUTIERREZ
Entity Type:Individual
Prefix:
First Name:JULISSA MARIE
Middle Name:GUTIERREZ
Last Name:TAVAREZ
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 1:52121 FILLMORE ST
Mailing Address - Street 2:
Mailing Address - City:THERMAL
Mailing Address - State:CA
Mailing Address - Zip Code:92274-9483
Mailing Address - Country:US
Mailing Address - Phone:760-587-0887
Mailing Address - Fax:
Practice Address - Street 1:535 N BRAND BLVD
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-1905
Practice Address - Country:US
Practice Address - Phone:877-206-1009
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-29
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician