Basic Information
| Provider Information | |||||||||
| NPI: | 1295192755 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BECERRIL | ||||||||
| FirstName: | JAIME | ||||||||
| MiddleName: | AREVALO | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ACSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AREVALO | ||||||||
| OtherFirstName: | JAIME | ||||||||
| OtherMiddleName: | BECERRIL | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | ACSW | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 1565 | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917291565 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099895699 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 16360 ROSCOE BLVD FL 2NF | ||||||||
| Address2: | |||||||||
| City: | VAN NUYS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914061219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8189014830 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2016 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | ASW60416 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.