Basic Information
| Provider Information | |||||||||
| NPI: | 1306015912 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVILEZ | ||||||||
| FirstName: | HERMAN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MA (CSULA) | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | AVILEZ | ||||||||
| OtherFirstName: | HERMAN | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | CERTIFICATION DRUG | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2568 S MYRTLE AVE | ||||||||
| Address2: | |||||||||
| City: | MONROVIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910165055 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234400733 | ||||||||
| FaxNumber: | 3237224450 | ||||||||
| Practice Location | |||||||||
| Address1: | 3316 W BEVERLY BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906401537 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237224529 | ||||||||
| FaxNumber: | 3237224450 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2008 | ||||||||
| LastUpdateDate: | 03/09/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251B00000X | N | Agencies | Case Management | 101YA0400X | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.