Provider Demographics
NPI:1124229877
Name:CEREZO, VICKY CARSULA
Entity type:Individual
Prefix:
First Name:VICKY
Middle Name:CARSULA
Last Name:CEREZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:VICKY
Other - Middle Name:PETALVER
Other - Last Name:CARSULA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1986
Mailing Address - Street 2:
Mailing Address - City:REDONDO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90278-7586
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 N LA BREA AVE
Practice Address - Street 2:7TH FLOOR
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1752
Practice Address - Country:US
Practice Address - Phone:310-677-7808
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist