Basic Information
| Provider Information | |||||||||
| NPI: | 1598251977 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VERDUSCO | ||||||||
| FirstName: | ALEXIS | ||||||||
| MiddleName: | RENE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 963 FORD ST | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928792314 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 27261 LAS RAMBLAS STE 220 | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92691 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099806700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/09/2018 | ||||||||
| LastUpdateDate: | 01/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 106H00000X | 116097 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.