Provider Demographics
NPI:1699524421
Name:ESPARZA, NELLY HAZEL
Entity type:Individual
Prefix:
First Name:NELLY
Middle Name:HAZEL
Last Name:ESPARZA
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 1:210 N BEECHWOOD AVE APT 451
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-7959
Mailing Address - Country:US
Mailing Address - Phone:909-942-1754
Mailing Address - Fax:
Practice Address - Street 1:210 N BEECHWOOD AVE APT 451
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-7959
Practice Address - Country:US
Practice Address - Phone:909-942-1754
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-14
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician