Provider Demographics
NPI:1932667417
Name:REDONA, DAMARIS I
Entity Type:Individual
Prefix:
First Name:DAMARIS
Middle Name:I
Last Name:REDONA
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 1:15 W HAWK ST APT 605
Mailing Address - Street 2:
Mailing Address - City:HEBER
Mailing Address - State:CA
Mailing Address - Zip Code:92249-9812
Mailing Address - Country:US
Mailing Address - Phone:442-237-8959
Mailing Address - Fax:
Practice Address - Street 1:15 W HAWK ST APT 605
Practice Address - Street 2:
Practice Address - City:HEBER
Practice Address - State:CA
Practice Address - Zip Code:92249-9812
Practice Address - Country:US
Practice Address - Phone:442-237-8959
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-04
Last Update Date:2019-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician