Provider Demographics
NPI:1770058505
Name:REBOLLOSO-SANCHEZ, LIRIO
Entity type:Individual
Prefix:
First Name:LIRIO
Middle Name:
Last Name:REBOLLOSO-SANCHEZ
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 1:2027 GRAND CANAL BLVD STE 21
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-6650
Mailing Address - Country:US
Mailing Address - Phone:209-425-3393
Mailing Address - Fax:
Practice Address - Street 1:2630 W RUMBLE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-0155
Practice Address - Country:US
Practice Address - Phone:209-222-2378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2024-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst