Basic Information
| Provider Information | |||||||||
| NPI: | 1770943854 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AGUAYO | ||||||||
| FirstName: | IVONE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 831 E ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093984383 | ||||||||
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| Practice Location | |||||||||
| Address1: | 831 E ARROW HWY | ||||||||
| Address2: | |||||||||
| City: | POMONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917672535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9093984383 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2016 | ||||||||
| LastUpdateDate: | 03/18/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | IMF85289 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
ID Information
| ID | Type | State | Issuer | Description | 7565A | 01 | CA | OUTPATIENT MENTAL HEALTH | OTHER |