Provider Demographics
NPI:1366989352
Name:CERVANTES VERDUZCO, ANGELICA LUCIA
Entity type:Individual
Prefix:
First Name:ANGELICA
Middle Name:LUCIA
Last Name:CERVANTES VERDUZCO
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 1:4630 BORDER VILLAGE RD STE N389
Mailing Address - Street 2:
Mailing Address - City:SAN YSIDRO
Mailing Address - State:CA
Mailing Address - Zip Code:92173-3121
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4630 BORDER VILLAGE RD STE N389
Practice Address - Street 2:
Practice Address - City:SAN YSIDRO
Practice Address - State:CA
Practice Address - Zip Code:92173-3121
Practice Address - Country:US
Practice Address - Phone:619-585-7686
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-27
Last Update Date:2025-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
106H00000X
CA18257101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist