Provider Demographics
NPI:1356836985
Name:AREVALO, NICOLE ANDREA
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANDREA
Last Name:AREVALO
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 1:2526 BUSH AVE
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94806-4530
Mailing Address - Country:US
Mailing Address - Phone:510-776-2038
Mailing Address - Fax:
Practice Address - Street 1:2526 BUSH AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94806-4530
Practice Address - Country:US
Practice Address - Phone:510-776-2038
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-26
Last Update Date:2018-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAXDJ93390961DOtherBLUE CROSS