Basic Information
| Provider Information | |||||||||
| NPI: | 1700357662 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GARIN | ||||||||
| FirstName: | AISSA | ||||||||
| MiddleName: | LEA | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | X | ||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PEREZ | ||||||||
| OtherFirstName: | AISSA | ||||||||
| OtherMiddleName: | LEA | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2418 CHRISTINA AVE | ||||||||
| Address2: | |||||||||
| City: | STOCKTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952041506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2099696546 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 441 S HAM LN STE A | ||||||||
| Address2: | |||||||||
| City: | LODI | ||||||||
| State: | CA | ||||||||
| PostalCode: | 952423525 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2092248940 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/17/2018 | ||||||||
| LastUpdateDate: | 04/04/2019 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | CA | N | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) | 106H00000X | 110482 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.