Basic Information
| Provider Information | |||||||||
| NPI: | 1891121836 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AVIRETT | ||||||||
| FirstName: | AMELIA | ||||||||
| MiddleName: | GARAHAN | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSED | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEONARD | ||||||||
| OtherFirstName: | AMELIA | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PPSC-S2 SCHOOL PSYCH | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1918 UNIVERSITY AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | BERKELEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 947043264 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5108411262 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2275 ARLINGTON DR | ||||||||
| Address2: | |||||||||
| City: | SAN LEANDRO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 945781132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103171444 | ||||||||
| FaxNumber: | 5104811605 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2013 | ||||||||
| LastUpdateDate: | 07/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 103TS0200X | 120021244 | CA | N | Behavioral Health & Social Service Providers | Psychologist | School | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.