Provider Demographics
NPI:1487002077
Name:CABELLOS, MAXIMILIANO
Entity type:Individual
Prefix:
First Name:MAXIMILIANO
Middle Name:
Last Name:CABELLOS
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 1:17130 VAN BUREN BLVD
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92504-5905
Mailing Address - Country:US
Mailing Address - Phone:323-332-7229
Mailing Address - Fax:
Practice Address - Street 1:11601 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90047-5006
Practice Address - Country:US
Practice Address - Phone:323-242-5000
Practice Address - Fax:323-328-1660
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2023-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF100745106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist