Basic Information
| Provider Information | |||||||||
| NPI: | 1659757805 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RUVALCABA | ||||||||
| FirstName: | BRANDON | ||||||||
| MiddleName: | |||||||||
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| Credential: | MSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1359 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917241016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264302853 | ||||||||
| FaxNumber: | 6263310035 | ||||||||
| Practice Location | |||||||||
| Address1: | 1359 N GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | COVINA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917241016 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6264302853 | ||||||||
| FaxNumber: | 6263310035 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/10/2015 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YM0800X | ASW91651 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 7068 | 05 | CA | MEDICAID | 6758 | 05 | CA | MEDICAID | 7420 | 05 | CA | MEDICAID |