Basic Information
| Provider Information | |||||||||
| NPI: | 1720394331 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AVELAR | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | EDWARD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 393 E WALNUT ST FL 3 | ||||||||
| Address2: | PHR GROUP PROVIDER ENROLLMENT UNIT | ||||||||
| City: | PASADENA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 911880001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8776080044 | ||||||||
| FaxNumber: | 8775140903 | ||||||||
| Practice Location | |||||||||
| Address1: | 8019 COMPTON AVE | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900013409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3235867333 | ||||||||
| FaxNumber: | 4242134840 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2010 | ||||||||
| LastUpdateDate: | 12/03/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/27/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | 28366 | CA | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.