Provider Demographics
NPI:1912180407
Name:PAVLIDIS, ATHANASE (LMFT)
Entity Type:Individual
Prefix:MR
First Name:ATHANASE
Middle Name:
Last Name:PAVLIDIS
Suffix:
Gender:M
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9850 19TH ST APT 58
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-4229
Mailing Address - Country:US
Mailing Address - Phone:909-989-9558
Mailing Address - Fax:
Practice Address - Street 1:9850 19TH ST APT 58
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91737-4229
Practice Address - Country:US
Practice Address - Phone:909-989-9558
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-07
Last Update Date:2007-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC35112106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist