Provider Demographics
NPI:1912653544
Name:ZAVALA ORTIZ, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:ZAVALA ORTIZ
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 1:222 E LAS TUNAS DR
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91776-1404
Mailing Address - Country:US
Mailing Address - Phone:626-320-1317
Mailing Address - Fax:
Practice Address - Street 1:222 E LAS TUNAS DR
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-1404
Practice Address - Country:US
Practice Address - Phone:626-320-1317
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-22
Last Update Date:2023-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1-22-57755103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst