Provider Demographics
NPI:1952693475
Name:SVIDERGOL, ALLISON BIRD
Entity Type:Individual
Prefix:
First Name:ALLISON
Middle Name:BIRD
Last Name:SVIDERGOL
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:PO BOX 549
Mailing Address - Street 2:
Mailing Address - City:LAKE ELSINORE
Mailing Address - State:CA
Mailing Address - Zip Code:92531-0549
Mailing Address - Country:US
Mailing Address - Phone:951-674-5354
Mailing Address - Fax:951-674-5227
Practice Address - Street 1:600 3RD ST STE C
Practice Address - Street 2:
Practice Address - City:LAKE ELSINORE
Practice Address - State:CA
Practice Address - Zip Code:92530-2748
Practice Address - Country:US
Practice Address - Phone:951-674-5354
Practice Address - Fax:951-674-5227
Is Sole Proprietor?:No
Enumeration Date:2011-05-03
Last Update Date:2011-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)