Provider Demographics
NPI:1265820575
Name:NEVAREZ-VIVOLO, DEBORAH
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:
Last Name:NEVAREZ-VIVOLO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:
Other - Last Name:NEVAREZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14890 JEREMIE ST
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-5628
Mailing Address - Country:US
Mailing Address - Phone:626-485-0424
Mailing Address - Fax:
Practice Address - Street 1:21125 CENTRE POINTE PKWY
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91350-2994
Practice Address - Country:US
Practice Address - Phone:855-435-3801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-08
Last Update Date:2025-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA122545106H00000X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7708OtherMEDI-CAL
CA7184OtherMEDI-CAL
CA7368OtherMEDI-CAL
CA7667OtherMEDI-CAL