Provider Demographics
NPI:1487113114
Name:PANDURO, FAVIOLA ALFARO
Entity type:Individual
Prefix:MRS
First Name:FAVIOLA
Middle Name:ALFARO
Last Name:PANDURO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:FAVIOLA
Other - Middle Name:
Other - Last Name:ALFARO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:290 WILSON AVE APT 206
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-3020
Mailing Address - Country:US
Mailing Address - Phone:951-722-7979
Mailing Address - Fax:
Practice Address - Street 1:18612 SANTA ANA AVE
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:CA
Practice Address - Zip Code:92316-2639
Practice Address - Country:US
Practice Address - Phone:909-421-7120
Practice Address - Fax:909-421-7128
Is Sole Proprietor?:No
Enumeration Date:2019-03-12
Last Update Date:2023-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
175T00000X
CA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No175T00000XOther Service ProvidersPeer Specialist