Basic Information
| Provider Information | |||||||||
| NPI: | 1457615288 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AGUSTINO | ||||||||
| FirstName: | RENY ADRIAN | ||||||||
| MiddleName: | JABAL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.A., B.C.B.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9531 PITTSBURGH AVE | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917306008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094842848 | ||||||||
| FaxNumber: | 9094843504 | ||||||||
| Practice Location | |||||||||
| Address1: | 9531 PITTSBURGH AVE | ||||||||
| Address2: | |||||||||
| City: | RANCHO CUCAMONGA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917306008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094842848 | ||||||||
| FaxNumber: | 9094843504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/26/2012 | ||||||||
| LastUpdateDate: | 06/26/2012 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103K00000X | 1-12-11716 | Y | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.