Basic Information
| Provider Information | |||||||||
| NPI: | 1356804165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUVALCABA | ||||||||
| FirstName: | JOEY | ||||||||
| MiddleName: | Q | ||||||||
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| Credential: | RADT (CCAPP) | ||||||||
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| Mailing Information | |||||||||
| Address1: | 133 PARK AVE APT 108 | ||||||||
| Address2: | |||||||||
| City: | SAN FERNANDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913403086 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8187446535 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 11600 ELDRIDGE AVE | ||||||||
| Address2: | |||||||||
| City: | LAKE VIEW TERRACE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 913426506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8186863000 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2019 | ||||||||
| LastUpdateDate: | 04/09/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | R1220251215 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.