Provider Demographics
NPI:1265599468
Name:TLAXCALA, SELENE (MS)
Entity type:Individual
Prefix:MS
First Name:SELENE
Middle Name:
Last Name:TLAXCALA
Suffix:
Gender:F
Credentials:MS
Other - Prefix:MS
Other - First Name:SELENE
Other - Middle Name:
Other - Last Name:TLAXCALA-CABRERA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MS
Mailing Address - Street 1:2008 DEERPARK DR
Mailing Address - Street 2:APT. #205
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92831-1589
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6301 BEACH BLVD
Practice Address - Street 2:#245
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-2840
Practice Address - Country:US
Practice Address - Phone:714-736-0231
Practice Address - Fax:714-736-0895
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 38861106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist