Provider Demographics
NPI:1134878085
Name:PALOS, CIENNA ALYSSE
Entity type:Individual
Prefix:
First Name:CIENNA
Middle Name:ALYSSE
Last Name:PALOS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1483
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-8483
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3 CORPORATE PLAZA DR
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-7905
Practice Address - Country:US
Practice Address - Phone:949-919-0428
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-19
Last Update Date:2025-04-15
Deactivation Date:2022-07-14
Deactivation Code:
Reactivation Date:2023-05-02
Provider Licenses
StateLicense IDTaxonomies
CAAPCC11177101YP2500X
CALMFT153758106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional