Provider Demographics
NPI:1104496728
Name:CERECEDES, NATALYA ALISSE (BACHELOR'S)
Entity type:Individual
Prefix:
First Name:NATALYA
Middle Name:ALISSE
Last Name:CERECEDES
Suffix:
Gender:F
Credentials:BACHELOR'S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13829 BLUEGRASS PL
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-5534
Mailing Address - Country:US
Mailing Address - Phone:650-676-0703
Mailing Address - Fax:
Practice Address - Street 1:13829 BLUEGRASS PL
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-5534
Practice Address - Country:US
Practice Address - Phone:650-676-0703
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-26
Last Update Date:2021-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician