Provider Demographics
NPI:1285932541
Name:AVALOS, MARIA CLEMENTINA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:CLEMENTINA
Last Name:AVALOS
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 1:2550 E FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91107-3406
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11263 CHIVERS AVE
Practice Address - Street 2:
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1518
Practice Address - Country:US
Practice Address - Phone:818-585-5679
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-09
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190096026103TS0200X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool
No171M00000XOther Service ProvidersCase Manager/Care Coordinator