Provider Demographics
NPI:1285491456
Name:PADRON, EMMANUEL PHILIP ANTONIO (APCC, PPS)
Entity type:Individual
Prefix:
First Name:EMMANUEL PHILIP
Middle Name:ANTONIO
Last Name:PADRON
Suffix:
Gender:M
Credentials:APCC, PPS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37856 BRUTUS WAY
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8049
Mailing Address - Country:US
Mailing Address - Phone:909-709-9205
Mailing Address - Fax:
Practice Address - Street 1:555 N PERRIS BLVD BLDG A
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-2811
Practice Address - Country:US
Practice Address - Phone:951-436-5300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-04
Last Update Date:2024-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15928101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty