Provider Demographics
NPI:1154935278
Name:BADAJOZ, SELENA
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:
Last Name:BADAJOZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8873 CAMPBELL AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92503-2406
Mailing Address - Country:US
Mailing Address - Phone:562-726-5764
Mailing Address - Fax:
Practice Address - Street 1:612 S MYRTLE AVE STE 100
Practice Address - Street 2:
Practice Address - City:MONROVIA
Practice Address - State:CA
Practice Address - Zip Code:91016-3406
Practice Address - Country:US
Practice Address - Phone:626-775-7888
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Multi-Specialty