Provider Demographics
NPI:1801286026
Name:AREVALO JIMENEZ, LILIANA YENISSAY
Entity type:Individual
Prefix:
First Name:LILIANA
Middle Name:YENISSAY
Last Name:AREVALO JIMENEZ
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 1:2629 CLARENDON AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90255-4119
Mailing Address - Country:US
Mailing Address - Phone:323-584-3700
Mailing Address - Fax:
Practice Address - Street 1:2629 CLARENDON AVE
Practice Address - Street 2:
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4119
Practice Address - Country:US
Practice Address - Phone:323-584-3700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-26
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW89802101YM0800X
CALCSW109988101YM0800X, 1041C0700X
171M00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program