Provider Demographics
NPI:1902115108
Name:AVIDANO, EUGENIA
Entity Type:Individual
Prefix:
First Name:EUGENIA
Middle Name:
Last Name:AVIDANO
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 1:1340 IMPERIAL BEACH BLVD
Mailing Address - Street 2:SUITE 204
Mailing Address - City:IMPERIAL BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:91932-3046
Mailing Address - Country:US
Mailing Address - Phone:619-565-2650
Mailing Address - Fax:619-565-2656
Practice Address - Street 1:1340 IMPERIAL BEACH BLVD
Practice Address - Street 2:SUITE 204
Practice Address - City:IMPERIAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:91932-3046
Practice Address - Country:US
Practice Address - Phone:619-565-2650
Practice Address - Fax:619-565-2656
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-05
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 50498106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist