Provider Demographics
NPI:1942639026
Name:AUDELO, CHRISTINA
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:
Last Name:AUDELO
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 1:1076 SANTO ANTONIO DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-8103
Mailing Address - Country:US
Mailing Address - Phone:909-433-9824
Mailing Address - Fax:909-433-9830
Practice Address - Street 1:17270 ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92508-9523
Practice Address - Country:US
Practice Address - Phone:951-683-6596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACAADE 4332-R101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)