Provider Demographics
NPI:1669161238
Name:NORIEGA, RAUL AMYAS
Entity type:Individual
Prefix:
First Name:RAUL
Middle Name:AMYAS
Last Name:NORIEGA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:RAUL
Other - Middle Name:AMYAS
Other - Last Name:VALLES DE NORIEGA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:222 W 6TH ST STE 230
Mailing Address - Street 2:
Mailing Address - City:SAN PEDRO
Mailing Address - State:CA
Mailing Address - Zip Code:90731-3332
Mailing Address - Country:US
Mailing Address - Phone:310-833-3135
Mailing Address - Fax:
Practice Address - Street 1:222 W 6TH ST STE 230
Practice Address - Street 2:
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90731-3332
Practice Address - Country:US
Practice Address - Phone:310-833-3135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-01
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136099101YM0800X
CAAMFT136099106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health