Provider Demographics
NPI:1194301523
Name:FABIAN MONTENEGRO, ZOILA REBECA
Entity type:Individual
Prefix:
First Name:ZOILA
Middle Name:REBECA
Last Name:FABIAN MONTENEGRO
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 1:1063 MCGAW AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-5554
Mailing Address - Country:US
Mailing Address - Phone:310-719-3908
Mailing Address - Fax:
Practice Address - Street 1:19750 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-1119
Practice Address - Country:US
Practice Address - Phone:310-719-3908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician