Provider Demographics
NPI:1285321737
Name:CLAVELLE, ERIC
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:CLAVELLE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:550 PAULARINO AVE APT J208
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-3234
Mailing Address - Country:US
Mailing Address - Phone:949-616-5758
Mailing Address - Fax:
Practice Address - Street 1:1910 N BUSH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-2816
Practice Address - Country:US
Practice Address - Phone:714-361-7950
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-24
Last Update Date:2023-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Yes172V00000XOther Service ProvidersCommunity Health Worker