Provider Demographics
NPI:1063172682
Name:CORTEZ, MICHELLE ANTONETTE (NONE)
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:ANTONETTE
Last Name:CORTEZ
Suffix:
Gender:F
Credentials:NONE
Other - Prefix:MISS
Other - First Name:MICHELLE
Other - Middle Name:ANTONETTE
Other - Last Name:CORTEZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NONE
Mailing Address - Street 1:18726 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90248-3813
Mailing Address - Country:US
Mailing Address - Phone:310-856-0800
Mailing Address - Fax:855-568-2494
Practice Address - Street 1:2155 CHICAGO AVE STE 203
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2209
Practice Address - Country:US
Practice Address - Phone:951-357-6926
Practice Address - Fax:855-568-2494
Is Sole Proprietor?:No
Enumeration Date:2021-12-22
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician