Provider Demographics
NPI:1770128399
Name:AVALOS, MIGUEL ANGEL
Entity type:Individual
Prefix:
First Name:MIGUEL
Middle Name:ANGEL
Last Name:AVALOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 ENCINAL AVE APT C
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-4086
Mailing Address - Country:US
Mailing Address - Phone:510-258-7601
Mailing Address - Fax:
Practice Address - Street 1:1266 14TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94607-2247
Practice Address - Country:US
Practice Address - Phone:510-273-4700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-07
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program