Basic Information
| Provider Information | |||||||||
| NPI: | 1619170958 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALDAVOUD | ||||||||
| FirstName: | FAZLOLLAH | ||||||||
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| Credential: | PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1460 TORREYANNA CIRCLE | ||||||||
| Address2: | |||||||||
| City: | CORONA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928828724 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515820895 | ||||||||
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| Practice Location | |||||||||
| Address1: | FIFTH AND WESTERN CALIFORNIA REHABILITATION CENTER | ||||||||
| Address2: | DEPT OF CORRECTIONS STATE OF CALIFORNIA | ||||||||
| City: | NORCO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 92860 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517372683 | ||||||||
| FaxNumber: | 9512732974 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/06/2007 | ||||||||
| LastUpdateDate: | 07/25/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/25/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | MFC 23813 | CA | N | Behavioral Health & Social Service Providers | Marriage & Family Therapist | 174400000X | 25147 | CA | N | Other Service Providers | Specialist | 103TC0700X | PSY 16601 | CA | Y | Behavioral Health & Social Service Providers | Psychologist | Clinical |
No ID Information.