Basic Information
| Provider Information | |||||||||
| NPI: | 1467086322 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ROELENS | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | A | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1375 W SAN BERNARDINO RD APT 253 | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917224405 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1020 S ARROYO PKWY | ||||||||
| Address2: | |||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911053911 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264032794 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/28/2020 | ||||||||
| LastUpdateDate: | 03/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | 118104 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health | 106H00000X | 118104 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 131870 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.