Provider Demographics
NPI:1174082671
Name:REBOLLAR, NERIC
Entity type:Individual
Prefix:
First Name:NERIC
Middle Name:
Last Name:REBOLLAR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7226 SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91405-2003
Mailing Address - Country:US
Mailing Address - Phone:818-235-1414
Mailing Address - Fax:
Practice Address - Street 1:44460 20TH ST W SIDE B
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2714
Practice Address - Country:US
Practice Address - Phone:714-834-1111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-14
Last Update Date:2025-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106S00000X
CA1-21-53138103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician