Provider Demographics
NPI:1285360354
Name:TRUJILLO, SELENA D
Entity type:Individual
Prefix:
First Name:SELENA
Middle Name:D
Last Name:TRUJILLO
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 1:25791 27TH ST
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92404-3435
Mailing Address - Country:US
Mailing Address - Phone:909-352-9917
Mailing Address - Fax:
Practice Address - Street 1:10604 N TRADEMARK PKWY
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5938
Practice Address - Country:US
Practice Address - Phone:909-484-2848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-29
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician