Provider Demographics
NPI:1497298798
Name:ALVIZURES, MIRIAM AMANDA
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:AMANDA
Last Name:ALVIZURES
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 1:2121 W TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90026-4915
Mailing Address - Country:US
Mailing Address - Phone:415-910-6044
Mailing Address - Fax:
Practice Address - Street 1:501 N EL CAMINO REAL STE 200
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-4789
Practice Address - Country:US
Practice Address - Phone:949-688-2933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-18
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YP2500X, 106H00000X
CA95632106H00000X
CA119180106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional